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CLINICAL  NOTES 


UTERINE    SURGEEY. 


WITH  SPECIAL   REFERENCE  TO   THE 


MANAGEMENT  OF  THE  STERILE  CONDITION. 


By  J.   MARION  SIMS,   A.B.,   M.D. 

LATE  StrKQEON  TO  THE  WOMAN'S  HOSPITAL,   NEW   YORK, 

Fellow  of  the  Now  York  Academy  of  Medicino  ;  of  the  New  York  Pathological  Society  ;  of  tlw 
New  York  Historical  Society  ;  of  the  New  York  State  Medical  Society  ;  of  the  lioyal  Medical 
and  Chiiurgical  Society,  London;  of  the  London  Medical  Society  ;  of  the  Pathological 
Society  ;  Hon.  Fellow  of  the  Obstetrical  Society,  London  ;  Honorary  Member  of  the 
•   German  Society  of  Physicians  and  NaturaUsts,  Paris  ;  Hon.  Fellow  of  the  Im- 
perial Academy  of  Medicine  of  Belgium ;  Knight  of  the  Legion  d'Honneur,  &c. 


NEW  YORK: 
WILLIAM    WOOD    &    CO.,    27    GREAT   JONES    ST. 

^873. 


Trow's 

Printing  and  Bookbinding  Co., 

205-213  Kast  j2t/i  St., 

NEW   YORK. 


TO 

SIK  JOSEPH  F.  OLLIFFE,  M.D., 

(UNIV,    PARIS), 

FELLOW  OP  THE  EOTAL  COLLEGE  OF  PHYSICIANS  (LOND.)  ;  PIITSICIAN  TO  HEE  MAJESTY'S  EiIBA8SJ 
AT  PAEIS  ;   OFFICER  OF  TIIH   LEGION   OP  HONOUn,   ETC.    ETC. 


My  Dear  Sir  Joseph, 

When  I  came  to  Europe,  now  more  than  three  years  ago,  I  had 
no  idea  of  remahiing  here  pennanently.  But  I  found  in  you  a 
warm  and  generous  friend,  whose  wise  counsels  and  noble  liberality 
elevated  me  at  once  into  a  most  favorable  position.  It  was  princi- 
pally through  your  influence  that  I  was  able  to  reach  the  highest 
circles  of  practice.  Without  you  my  sojourn  here  would  have  been 
temporary  and  fruitless. 

Let  me  assure  you,  my  dear  Sir  Joseph,  that  it  is  not  only  to 
you,  as  a  learned  and  accomplished  Physician,  whose  great  talents 
and  attainments  have  placed  him  so  desers^edly  in  the  foremost  ranks 
of  his  Profession ;  but  it  is  also  to  you  as  a  true  man  of  noble 
impulses  and  generous  nature;  it  is  to  you  as  a  Friend,  when  I  most 
needed  a  cheering  comforting  word,  that  I  now  come  with  this 
Volum<^,  and  beg  you  to  accept  it  simply  as  a  token  of  Gratitude 
for  the  many  acts  of  kindness  and  friendship  which  you  have  so 
lavishly  bestowed  upon  me. 

J.    MARION    SIMS. 


PREFACE. 


In  1862,  I  voluntarily  left  my  own  country,  on  account  of  its 
political  troubles.  Our  unfortunate  civil  war  continued  much 
longer  than  any  of  us,  North  or  South,  anticipated.  In 
consequence  of  this  my  residence  abroad  was  prolonged  far 
beyond  my  original  intention.  I  therefore  had  time  to  look 
over  my  note-books,  and  to  cull  such  facts  as  illustrate  the 
method  of  treating  Uterine  Disease  at  the  Woman's  Hospital. 
These  facts  are  strung  together  in  the  form  of  these  "  Notes." 

Having  an  innate  horror  of  writing,  I  have  not  tried  to  make 
a  book ;  on  the  contrary,  I  have  simply  related  in  detail  my 
various  operations,  and  given  the  history  of  cases  in  which 
circumstances  led  me  to  adopt  a  modified  procedure,  or  for 
which  I  have  devised  new  forms  of  instruments. 

A  clinical  report  of  this  sort  very  naturally  divides  itself  into 
groups  of  cases  which  may  be  made  illustrative  of  the  principles 
of  practice. 

In  my  own  country  my  contributions  have  generally  been 
received  with  kindness ;  and  although  I  have  reason  to  hope 
that  they  will  have  a  friendly  reception  here,  still,  as  I  make  no 
literary  pretensions,  it  is  with  the  greatest  diffidence  that  I 
appear  as  an  author  on  this  side  of  the  Atlantic. 

As  its  title  indicates,  this  collection  of  "  Clinical  Notes"  lays 
no  claim  whatever  to  the  character  of  a  systematic  work.  It  is 
simply  a  voice  fron   the  Woman's   Hospital,   which,  in   all 


VI 


PREFACE. 


probability,  would  never  have  beea  heard  if  I  had  remained  at 
home.  I  wish  most  sincerely  that  I  could  have  produced  some- 
thing more  worthy  of  the  position  so  long  held  by  me  in  that 
noble  Charity  ;  for  to  this  I  owe  all  that  I  know  practically  of 
the  subjects  herein  treated. 

In  looking  over  this  volume,  it  would  seem  that  I  owe  an 
apology  to,  and  must  claim  the  indulgence  of,  my  brethren  for 
three  things : — 

1st.  A  clinical  review  of  personal  experience,  taken  from 
note-books,  as  this  has  been,  must  almost  of  necessity  be  written 
in  the  first  person. 

2nd.  It  may  be  necessary  to  excuse  to  my  senior  readers  the 
minuteness  of  detail  in  which  I  have  sometimes  indulged  ;  but, 
at  the  same  time,  I  must  plead  the  necessity  of  such  minuteness 
for  the  guidance  of  my  younger  brethren,  for  whom  principally 
these  pages  were  penned. 

3rd.  The  illustrations  are  not  all  as  good  as  I  would  have  had 
them.  Most  of  them  are  mere  diagrams  made  by  myself.  For 
any  inaccuracies  I  alone  am  responsible ;  for  any  artistic  value 
that  they  may  possess,  the  credit  is  wholly  due  to  Leveille, 
Lackerbauer,  and  Yien,  of  Paris ;  and  to  Mr.  Orrin  Smith,  of 
London. 

A  word  of  explanation  on  another  point.  It  will  be  seen 
that  I  have  not  touched  upon  the  accidents  of  parturition,  such 
asfistulie  of  the  bladder,  rectum,  and  vagina,  lacerated  perineum, 
&c.  It  is  only  just  to  myself  to  say  that  I  have  ignored  these 
for  the  present,  because  I  hope,  if  time  and  circumstances 
permit,  to  prepare,  at  no  distant  day,  a  fully  illustrated  mono- 
graph on  these  subjects.  To  have  done  them  ample  justice  here 
would  have  interfered,  in  some  sort,  with  the  plan,  and  aug- 
mented very  considerably  the  size  of  this  volume. 


PREFACE.  Yii 

In  conclusion  I  beg  leave  to  say  that  I  am  under  special 
obligations  to  Dr.  Thos,  D.  Pratt  for  timely  aid ;  and  I  take  tlii? 
occasion  to  return  my  sincere  tbanks  to  my  friend,  Mr.  Ernest 
Hart,  for  useful  suggestions  and  valuable  assistance  rendered  as 
these  pag6s  were  passing  through  the  press. 


London  :  1,  Bolton  Row,  May  Faib, 
1st  January^  1860. 


CONTENTS. 


Introduction, ,,,.l 

On  the  Method  of  Uterine  Examination, 6 

SECTION  L 

Conception  occurs  onlt  during  Menstrual  Life,        ....  27 

Early  Pregnancy, 29 

Conception  without  Menstruation,      .......  30 

Errors  in  Diagnosis, 32 

False  Quickening, 34 


SECTION  n. 

Menstruation  should  be  suon  as  to  snow  a  Healthy  Condition  of 


THE  Uterine  Cavity, 

Scanty  Menstruation,  .        .        . 

Profuse  Menstruation, 

Menorrhagia  from  Granular  Erosion, 

FROM  Fibrous  Engorgement  of  the  Cervix, 

FROM  Fungoid  Granulations, 
Sponge  Tents,  how  to  make  and  introduce, 

Sea  Tangle  Tent, 

Menorrhagia  from  Polypus,        .... 
Use  of  Glycerine  in  Uterine  Surgery, 
Diagnosis  of  Polypous  Tumours, 

The  Ecraseur, 

Intra-Uterine  Polypi, 

Polypi  of  the  Fundus  and  Posterior  Wall, 
The  Operation  for  the  Removal  of  Polypi, 
Fibroid  Tumours, 


37 
39 
41 
43 
44 
46 
47-65 
66 
67 
71 
72 
76 
82 
86 
90 
94 


X  CONTENTS. 

Uterine  Probes, 104 

Menorrhagia  from  Inversion  of  the  Uterus,       ....  123 

Painful  Menstruation, 138 

Incision  of  the  Os  and  Cervix, ■  153 

SECTION  III. 

The  Os  and  Cervix  Uteri  should  be  sufficiently  open,  not  only  to 

PERMIT  THE    FrEE  ExIT  OF   THE    MeNSTRUAL    FlOW,    BUT    ALSO    TO 

ADMIT  THE  Ingress  of  the  Spermatozoa, 175 

Normal  Conditions  and  Relations  of  the  Uterus,        .        .         .  175 

Anomalies, 178 

Os  TiNc^ — abnormal, 181 


SECTION  IV. 

The  Cervix  Uteri  should  be  of  Proper  Size,  Form,  and  Density,       .  197 

Hypertrophic  or  Defective  Development  of  Cervix  Uteri,         .  200 

Method  of  Amputation, 201 

Proper  Form  of  the  Cervix,         .......  213 

Illustrations  of  the  Conical  Cervix, 216 

Induration  of  the  Cervix, 222 


SECTION  V. 

The  Uterus  should  be  in  a  Normal  Position,  i.  e, 

VERTED  NOR  ReTROVERTED  TO  ANY  GREAT  DEGREE 

Position  and  Relations  of  the  Pelvic  Organs, 

Uterine  Displacements, 

Anteversion, 

Retroversion, 

Pessaries, 

Procidentia  Uteri, 


neither  Ante- 


226 

227 
229 
232 
249 
264 
287 


SECTION  VI. 

The  Vagina  must  be  capable  of  Receiving  akd  Retaining  the  Sper- 
matic Fluid, .  313 

Imperforate  Hymen, 315 

Vaginismus, 317 

Atresia  Vagina. 326 

Absentia  VAGiNiE, 340 

Short  Vagina, 342 

NoN-RETAINING  VaGINA, 345 


CONTENTS. 


XI 


SECTION  VII. 

For  Conception,  Semen  with  Living  Spermatozoa  sqould  be  depositkd 
IN  TOE  Vagina  at  the  peoper  time,    . 
Nature  and  Properties  of  Semen, 

Spermatozoa, 

Artificial  Fertilization, 
Period  for  Conception, 


349 
351 
352 
364 
371 


SECTION  VIII. 

The  Siccretions  of  the  Ckrvix  and  Vagina  should  not  poison  or  kill 

the  Spermatozoa, 377 

The  Vaginal  Secretions, 379 

Vaginitis, 379 

Leucorrhcea, 383 

Vaginal  Injection, 385 

Endo-Cervicitis, 391 

Cervical  Mucus, 393 

Intra-Uterine  Abscess, 396 

Endo-Metritis, 397 


UTERINE    SURGERY. 


INTRODUCTION. 

I  i>o  not  propose  to  write  a  complete  monograph  on  Ute* 
rine  Surgery,  or  on  the  treatment  of  sterility,  but  simply 
to  interweave  the  two,  while  taking  a  glance  at  such 
surgical  difficulties  as  seem  ordinarily  to  interfere  with 
conception.  To  make  a  work  of  this  sort  complete  would 
be  to  write  a  book  on  all  the  diseases  of  women,  and  on 
some  of  those  of  the  opposite  sex.  But  this  is  not  my 
object,  and  I  shall  confine  myself  to  the  consideration  of 
such  cases  as  ordinarily  come  under  the  observation  of 
the  practitioner. 

An  inquiry  into  the  conditions  favourable  to  concep- 
tion would  almost  necessarily  involve  a  consideration  of 
those  opposed  to  it ;  and  this  would  lead  very  naturally 
to  the  investigation  of  the  best  means  of  overcoming 
such  obstacles.  This  is  the  order  in  which  I  propose  to 
consider  the  subject ;  but  it  is  not  the  one  by  which  my 
experience  was  gained.  It  came  by  a  very  different  pro- 
cess. 

In  the  course  of  treating  the  diseases  of  women,  I,  like 
others  similarly  engaged,  found  many  cases  of  sterility 
accidentally  cured  simply  by  curing  some  uterine  affec- 
tion. After  a  while  I  discovered  that  they  were  as 
various  and  as  varying  as  the  diseases  upon  which  they 
depended.    Then,  by  a  classification  of  all  diseases  of  the 


2  UTERINE  SURGERY. 

uterus  just  as  they  were  encountered,  I  found  sterility  to 
be  incident  to  many  of  them.  These  naturally  arranged 
themselves  into  two  classes ;  viz., — 1st.  Those  who  had 
never  conceived ;  and — 2nd.  Those  who  had  ;  but  who 
for  some  reason  had  ceased  to  do  so  for  a  time,  say  five 
years,  or  more.  The  first  I  called  "  Natural  Sterility  ; " 
the  second,  "  Acquired  Sterility." 

In  looking  over  my  note-books  for  a  series  of  years,  I 
was  surprised  to  see  how  nearly  equal  these  two  classes 
were.  Sometimes  one  and  then  the  other  would  predo- 
minate ;  but  they  were  so  evenly  balanced,  that  from  3 
to  6  per  cent,  would  cover  the  variation  either  way. 

I  mean  that  this  is  so,  taking  all  cases  of  uterine  dis- 
ease as  they  are  promiscuously  presented.  If  we  consider 
the  cases  of  those  only  who  come  to  consult  us  merely 
on  the  subject  of  sterility,  without  reference  to  disease 
or  actual  suffering,  the  first  class  will,  of  course,  greatly 
predominate.  But  it  is  by  a  study  of  all,  that  we  de- 
duce the  principles  that  are  to  guide  our  judgment  in 
individual  cases.  It  is  by  this  that  we  are  able  to  specify 
the  conditions  most  opposed  to  conception ;  and,  at  the 
same  time,  those  most  favorable  to  it. 

The  trouble  in  one  case  may  depend  upon  mere  con- 
traction of  the  OS  ;  in  another  upon  malformation  of  the 
same — in  another  upon  engorgement  of  the  cervix — in 
another  upon  elongation — in  another  upon  hypertrophy 
— in  another  upon  simple  induration — in  another  upon 
curvature  of  the  canal  of  the  cervix — in  another  upon 
polypus — in  another  upon  a  fibroid — in  another  upon 
malposition  of  the  uterus — in  another  upon  some  anato- 
mical anomaly  or  malformation  of  the  vagina — in  ano- 
ther upon  vitiated  secretions  of  the  cervix — in  another 
upon  those  of  the  vagina,  the  one  generally  acting  me- 
chanically, the  other  chemically — in  another  upon  the 


INTRODUCTION.  3 

absence  of  spermatozoa ;  while  others  may  be  compli- 
cated with  several  of  these  anomalies  all  subjects  of 
study  and  investigation. 

And  when  we  come  to  analyze  these  various  causes 
and  complications,  they  are  resolved  into  one  great  gene- 
ral principle,  embracing  all  manner  of  obstructions  to 
the  free  passage  of  living  spermatozoa  into  the  cavity  of 
the  womb.  In  all  curable  cases  ovulation  must  be  per- 
fect, and  the  faulty  link  must  be  found  in  defective  fruc- 
tification, or  else  all  our  efforts  are  in  vain.  If  the  wo- 
man has  passed  the  period  of  ovulation,  of  course  we 
can  do  nothing  for  her.  If  the  ovum  never  passes  into 
the  fallopian  tubes,  a  thing  impossible  to  determine,  it  is 
equally  beyond  remedy.  We  may  safely  assume  a  nor- 
mal menstruation  as  a  sign  of  normal  ovulation.  This 
being  our  guide,  we  may  hope,  in  the  majority  of  cases, 
to  find  some  of  the  troubles  above  enumerated,  many  of 
which  are  eventually  curable. 

It  is  self-evident  that  if  we  knew  exactly  all  the 
conditions  of  the  uterus  and  its  appendages  absolutely 
essential  to  fecundation,  it  would  not  be  very  diflicult  to 
determine,  in  any  given  case,  in  what  particular  it  dif- 
fered from  the  proper  standard.  And,  on  the  other 
hand,  if  we  knew  exactly  the  conditions  of  the  uterus 
and  appendages  absolutely  opposed  to  fecundation,  it 
would  not  be  very  difficult  to  determine  at  once  the 
chances  of  cure. 

This  is  but  another  way  of  saying  that  here,  as  in 
every  other  department  of  medicine,  knowledge  of  both 
normal  action  and  abnormal  condition  is  essential  to  safe 
and  sure  methods  of  treatment. 

A  few  years  ago,  the  subject  of  conception  was 
wrapped  in  the  profoundest  mystery ;  but  now,  thanks 
to  the  labours  of  Martin  Barry,  of  Bischofi^,  of  Coste,  of 


4  UTERINE   SURGERY. 

Pouchet,  and  otlier  modern  physiologists,  its  laws  are 
much  better  understood. 

As  usual,  pathology  is  here  behind  its  great  pioneer, 
physiology,  and  yet  quite  in  advance  of  therapeutics  ; 
for  until  a  comparatively  recent  period  we  had  no 
rational  views  on  the  treatment  of  the  sterile  condition  ; 
and  almost  all  that  is  now  known  has  emanated  from 
the  Edinburgh  school.  Indeed,  little  or  nothing  has 
been  added  to  the  labours  of  Mcintosh  and  of  Simpson  ; 
and  the  English  language  presents  us  with  but  one  com- 
plete monograph  on  the  subject, — that  by  Dr.  A.  K. 
Gardner,*  of  New  York. 

Macintosh  f  discovered  that  most  of  his  sterile  pa- 
tients had  a  contracted  os  and  cervix ;  and  he  con- 
ceived the  idea  of  dilating  these  by  bougies,  such  as 
were  used  ordinarily  for  stricture  of  the  urethra.  His 
success  was  very  remarkable,  but  none  of  his  followers 
were  able  to  attain  equally  good  results.  Simpson, 
seeing  the  uncertainty  and  even  danger  of  dilatation, 
had  the  happy  thought  of  incising  the  os  and  cervix 
to  render  their  enlargement  more  thorough  and  more 
permanent.  The  results  have  not  been  all  that  were 
hoped  for  ;  but  enough  has  been  done  to  show  that 
we  are  at  last  on  the  highway  of  improvement  ;  and 
it  seems  to  me  that  further  advances  must  be  made 
as  heretofore,  by  means  almost  purely  surgical. 

From  any  point  of  view  this  subject  is  one  of  great 
importance  ;  for  the  perpetuation  of  names  and  families, 
the  descent  of  property,  the  happiness  of  individuals, 
and  occasionally  the  welfare  of   the  State,  and   even 


*  "  On  the  Causes  and  Curative  Treatment  of  Sterility,"  by  A.  K.  Gard« 
ner,  M.D.,  &c.,  New  York.     1856. 
t  Macintosh's  "  Pathology  and  Practice  of  Physic." 


INTRODUCTION.  5 

tte   permanence   of  dynasties   and   governments,  may 
depend  upon  it. 

Without  further  preliminary  remarks,  let  us  then 
inquire,  "What  are  the  conditions  essential  to  Con- 
ception ?", 

1. — It  occurs  only  during  menstrual  life. 

2. — Menstruation    should    be    such    as   to    show    a 

healthy  state  of  the  uterine  cavity. 
3. — The  OS   and   cervix  uteri   should  be   sufficiently 
open  to  permit   the  free  exit  of  the  menstrual 
flow,    and    also   to   admit   the    ingress    of    the 
spermatozoa. 
4. — The   cervix  should   be  of    proper   form,   shape, 

size,  and  density. 
5. — The  uterus  should  be  in  a  normal  position,  i.e.^ 
neith^.r    ante-verted,    nor    retro-verted    to   any 
great  degree. 
6. — ^The  vagina  should  be  capable  of  receiving  and 

of  retaining  the  spermatic  fluid. 
v. — Semen,    with     living     spermatozoa,    should     be 

deposited  in  the  vagina  at  the  proper  time. 
8.-  -The  secretions  of  the  cervix  and  vagina  should 
not  poison  or  kill  the  spermatozoa. 
I    lay    these    down    as    postulates,  embracing   the 
general    principles   or   laws   most   favourable — indeed, 
essential  to   fecundation  ;  and  I  propose  to  take  them 
up   seriatim,   and   to   show,    from    clinical   experience, 
wherein  the  sterile  "condition  differs  from  the   fecund, 
and  to  point  out,  so  far  as  we  know,  the  surest  methods 
of  relief. 

But  before  entering  upon  this  discussion,  it  will  be 
well,  perhaps,  to  say  something 

On  the  Method  of  Uterine  Examination. — Almost 


g  UTERINE  SURGERY. 

every  physician  accustomed  to  treat  the  diseases  of 
women  has  educated  himself  to  some  peculiar  method 
of  examination.  I  propose  here  to  give  my  own 
plan. 

Every  thorough  uterine  investigation  is  naturally 
divided  into  two  stages,  the  first  requiring  the  touch, 
the  second  the  sight  ;  the  dorsal  decubitus  for  the 
one,  the  left  lateral  for  the  other.  For  the  touch 
alone,  the  patient  may  lie  on  a  sofa  or  a  bed ;  but  the 
one  is  too  low,  and  the  other  too  soft  and  yielding,  for 
a  speculum  examination.  I  therefore  prefer  a  common 
table,  two  or  three  feet  wide,  and  four  or  five  feet  long, 
covered  with  a  wadded  quilt,  or  blankets  folded.  This 
is  a  little  more  formidable,  but  it  is  better  for  both 
physician  and  patient.  Indeed,  it  is  essential,  if  we 
wish  to  make  a  very  thorough  examination.  The  table 
being  properly  prepared,  the  patient  is  requested  to 
loosen  all  the  fastenings  of  the  dress  and  corsets,  so 
that  there  may  be  nothing  to  constrict  the  waist  or  to 
compress  the  abdomen.  While  this  is  being  done,  the 
physician  should  bathe  his  hands  in  warm  water,  and 
wash  them  well.  It  may  seem  odd  to  insist  upon  this, 
but  I  do  most  earnestly  ;  1st,  because  it  softens  and 
warms  the  hands  ;  2nd,  because  it  insures  their  clean- 
ness ;  and  3rd,  because  it  assures  our  patient  against 
any  dread  of  contamination  by  the  touch,  a  thing  by 
no  means  to  be  despised. 

All  being  ready,  the  patient  is  now  requested  to  sit 
on  the  edge  of  the  table,  and  then  to  lie  down  on  the 
back,  with  -the  head,  but  not  the  shoulders,  supported 
by  a  pillow,  while  the  feet  rest  momentarily  on  a  chair. 

Many  practitioners  allow  the  feet  to  hang  down, 
each  on  a  chair,  but  this  is  by  no  means  the  best  plan 
for  either  physician  or  patient,  nor  is  it  the  most  deli- 


INTKODUCTION.  ^l 

cate.  As  soon  as  the  patient  is  laid  comfortably  back 
on  the  table,  tbe  surgeon  will  raise  her  feet  from  the 
chair,  upon  which  he  is  now  to  sit  down,  and  place 
them  on  the  edge  of  the  table,  with  the  heels  separated 
some  ten  or  twelve  inches,  while  the  knees  are  a  little 
wider  apart.  This  flexure  of  the  thighs  and  legs  in- 
sures the  relaxation  of  the  abdominal  walls.  Some 
patients  will  at  first,  in  spite  of  our  entreaties,  place 
the  soles  of  the  feet  together,  and  let  the  knees  fall 
widely  apart,  while  others  will  unconsciously  hold  the 
knees  closely  together,  and  brace  the  feet  firmly  out- 
wards, each  condition  being  equally  opposed  to  an  easy 
exploration  of  the  vagina. 

The  patient  once  on  the  back,  with  the  extremities 
properly  flexed  and  fixed,  must  be  assured  that  there 
is  to  be  neither  pain  nor  exposure  of  person  ;  this  last 
being  more  dreaded  than  the  most  intense  suffering. 

Everything  being  ready,  let  the  left  index  finger  be 
well  lubricated,  not  with  sweet  oil,  which  is  often 
gummy  and  sticky,  nor  with  grease,  which  is  often 
rancid,  but  with  warm  water  and  Castile  or  other  fine 
soap,  which  is  a  cleaner,  cheaper,  and  better  lubricant 
than  any  other.  Pass  the  finger  into  the  vagina — do  it 
gently — if  otherwise,  we  may  jar  the  nervous  system, 
and  produce  involuntary  sj^asmodic  action  of  the  abdo- 
minal muscles.  The  patient  may  become  agitated  and 
alarmed,  and  we  may  perhaps  be  compelled  to  pro- 
crastinate a  very  minute  examination  to  some  future 
*time.  As  the  finger  passes,  let  it  ascertain  if  there  is 
anything  abnormal  about  the  ostium  vaginae.  Is  it 
contracted,  rigid?  Is  the  hymen  present  or  absent? 
Is  it  irritable  or  tender?  Then  as  to  the  vagina :  Does 
it  dip  down  towards  the  coccyx  ?  Does  it  run  more  in 
the  direction  of  the  axis  of  the  pelvis  ?     Is  it  of  normal 


g  •     UTERINE    SURGERY, 

temperature?  Is  it  short?  Is  it  deep?  Is  it  nar- 
row ?  Is  it  capacious  ?  Does  it  contain  any  foreign 
body  ?  If  so,  is  it  something  inorganic,  previously  in- 
troduced? Or,  is  it  something  organic,  growing  on 
the  walls  of  the  vagina,  on  the  os  tincse,  or  does  it  come 
from  the  cavity  of  the  uterus  ?  Is  it  benign  or  malig- 
nant? Then  what  of  the  womb?  Is  the  os  open  or 
closed,  large  or  small  ?  Is  the  cervix  too  long,  too 
pointed,  too  small,  too  large  ?  Is  it  indurated  or 
ulcerated  ?  Is  the  body  of  the  organ  in  its  proper 
position?  Is  it  ante-verted,  retro-verted,  or  flexed  in 
any  direction  ?  Is  it  larger  or  smaller  than  natural  ? 
Is  it  of  proper  form  ?  Is  it  indurated  ?  Is  it  fixed  or 
movable  ?     Is  there  any  comj)lication,  ovarian  or  fibroid  ? 

All  of  these  conditions  are  ascertainable  by  the  touch 
alone.  We  need  no  speculum  to  tell  us  of  the  volume, 
position,  and  relations  of  the  uterus  and  its  appendages. 

But  I  should  not  omit  to  say  that  the  mere  touch 
by  the  vagina  is  not  alone  sufficient. 

It  is  necessary  to  make  pressure  Avith  the  right  hand 
on  the  abdomen  in  the  hypogastric  region  at  the  same 
time  that  the  left  index  is  carried  into  the  vagina.  The 
two  hands  then  act  conjointly  in  ascertaining  the  con- 
dition and  relations  of  the  uterus. 

Is  it  in  its  normal  position?  Then  the  os  uteri 
will  rest  on  the  end  of  the  left,  index  finger,  while  the 
fundus  wiU  be  distinctly  felt  by  the  other  hand,  in  a  line 
drawn  from  the  os,  in  the  direction  of  the  umbilicus. 

Is  it  ante-verted  ?  Then  the  os  will  be  very  far  back 
towards  the  hollow  of  the  sacrum,  while  the  fundus  will 
be  felt  by  the  index  just  behind  the  symphysis  pubis, 
pressing  down  upon  and  perhaps  parallel  with  the 
anterior  wall  of  the  vagina. 

But  I  repeat  that  the  touch  by  the  vagina  is  not 


INTRODUCTION. 


enough  to  determine  this  point  positively,  and  it  is 
essential  always  to  make  pressure  at  the  same  time 
with  the  other  hand,  just  above  the  23ubes.      It  will 


Fig.  1. 


then  be  very  easy  to  measure  the  size  and  shape  of  the 
body  of  the  womb,  for  it  will  be  held  firmly  between 
the  fingers  of  the  two  hands,  and  its  outline  and  irre- 
gularities will  be  ascertained  with  as  much  nicety  as  if 
it  were  outside  of  the  body.  Thus  isolated,  we  deter- 
mine its  condition  as  easily  as  we  would  that  of  a  pear 
wrapped  up  in  a  common  towel  or  napkin. 

The  retro-uterine  region,  represented  here  as  being 
occupied  by  a  small  tumour,  is  quite  as  easily  explored 
by  the  touch  alone.  To  do  this,  pass  the  left  index 
finger  to  the  posterior  mil  de  sac^  hook  it  up  behind 
the  cervix  uteri,  raise  this  upwards,  draw  it  forwards, 
and  at  the  same  time  press  the  outer  hand  in  the 
direction  of  the  point  of  the  left  index. 

In  a  thin  subject,  where  there  is  nothing  abnormal, 


10 


UTERINE  SURGERY. 


the  external  fingers  and  the  internal  one  can  be 
brought  very  near  together  behind  the  cervix,  with- 
out pain  to  the  patient  or  inconvenience  to  the 
operator;  and  if  there  is  anything  abnormal,  this 
manipulation  is  sure  to  detect  it. 

We  may  now  and  then  be  obliged  to  pass  the  fiuger 
into  the  rectum  to  clear  up  some  doubtful  point ;  but 
this  is  rarely  necessary. 

By  this  method,  versions,  flexions,  fibroid  offshoots, 
and  other  irregularities,  are  readily  detected  ;  and  if 
at  any  time  there  is  a  doubt  about  the  direction  or 
depth  of  the  uterine  cavity,  the  sound  will  at  once 
clear  it  up. 

Having  ascertained  all  these  points  by  the  touch, 
we  are  ready  for  the  second  stage  of  the  examination — 
viz.,  that  by  the  speculum.  As  before  said,  for  the 
digital  examination,  the  dorsal  decubitus  is  preferable  ; 
but  for  the  speculum,  the  left  lateral  semi-prone  position 
is  the  best. 

In  1845  I  first  used  my  speculum  for  vesico- vaginal 
fistula  operations,  placing  the  patient  on  the  knees.  I 
rarely  resort  to  this  method  now,  but  as  it  may  some- 
times be  necessary  in  a  complicated  case  of  vesico-vaginal 
fistula,  or  in  some  forms  of  malignant  disease,  I  shall 
here  quote  the  following  from  my  first  paper  on  this 
subject,  jDublished  in  the  American  Journal  of  Medical 
Sciences^  January,  1852. 

"In  order  to  obtain  a  correct  view  of  the  vaginal 
canal,  I  place  the  patient  on  a  table,  about  two  and  a 
half  by  four  feet,  on  her  knees,  with  the  nates  ele- 
vated and  the  head  and  shoulders  depressed.  The 
knees  must  be  separated  some  six  or  eight  inches, 
the  thighs  at  about  right  angles  with  the  table, 
and   the    clothing    all    thoroughly    loosened,  so    that 


INTRODUCTION. 


n 


there  shall  be  no  compres- 
sion of  the  abdominal  pa- 
rietes.  An  assistant  on  each 
side  lays  a  hand  in  the  fold 
between  ,the  glutei  muscles 
and  the  thigh,  the  ends  of 
the  fingers  extending  quite 
to  the  labia  majora  ;  then  by 
simultaneously  pulling  the 
nates  upwards  and  outwards, 
the  OS  externum  opens,  the 
pelvic  and  abdominal  viscera 
all  gravitate  towards  the  epi- 
gastric region,  the  atmosphere 
enters  the  vagina,  and  by 
its  pressure,  soon  stretches 
this  canal  out  to  its  utmost 
limits,  affording  an  easy  view 
of  the  OS  tincsQ,  fistula,  <fec. 
To  facilitate  the  exhibition 
of  the  parts,  the  assistant 
on  the  rio:ht  side  of  the 
patient  introduces  into  the 
vagina    the    lever  sj^eculum,  j^i^.  2. 

represented     in    fig.    2,  and 

then,  by  lifting  the  perineum,  stretching  the  sphincter, 
and  raising  up  the  recto-vaginal  septum  (fig.  3),  it  is 
as  easy  to  view  the  whole  vaginal  canal  as  it  is  to 
examine  the  fauces,  by  turning  a  mouth  widely  open  to 


a  stronsf  li^rht. 


"This  method  of  exhibiting  the  parts  is  not  only 
useful  in  these  cases,  but  in  all  affections  of  the  os 
and  cervix  uteri  requiring  ocular  inspection. 

"  The  most  painful  organic  diseases,  such  as  corroding 


12 


UTERINE  SURGERT. 


ulcer,  carcinoma,  <fec,,  may  be  thus  exposed  without 
inflicting  the  least  pain,  while  any  local  treatment  may 
be  instituted  without  danger  of   injuring  the  healthy 


Fig.  3. 


structures.  By  this  method  also  a  proper  estimate? 
anatomically,  can  be  had  of  the  shape  and  capacity  of 
the  vagina  ;  for  where  there  is  no  organic  change, 
BO  contraction,  and  no  rigidity  of  it  from  sloughs, 
ulcers,  or  cicatrices,  and  where  the  uterus  is  movable, 
this  canal  immediately  swells  out  to  an  enormous 
extent." 

Thus  I  wrote  in  1852 ;  and  I  have  introduced  figs. 
2  and  3,  copied  from  the  American  Journal  of  Medical 
Sciences  of  that  date,  merely  for  the  purpose  of  con- 
trasting my  past  and  present  methods  of  vaginal 
exploration. 


INTRODUCTION. 


13 


Many  persons  who  have  never  witnessed  ihe  use  of 
my  speculum,  doubt  the  correctness  of  my  explanation 
of  its  rationale  as  given  above.  But  let  such  experi- 
ment for  themselves,  and  give  us  a  rationale  more  in 
accordan'ce  with  the  laws  of  natural  philosophy,  if  they 
have  one.  For  a  successful  experiment  certain  con- 
ditions are  requisite.  At  the  risk  of  being  tedious, 
I  will  reiterate  them.  Let  the  experimenter  first 
loosen  all  the  strings  and  fastenings  of  the  dress  and 
corsets,  and  then  place  the  patient  on  a  table  on 
her  knees,  and  bend  her  body  forwards  till  the  head  is 
brought  down  to  the  plane  of  the  table,  where  it  may 
rest  in  the  two  hands,  its  weight  supported  on  the  left 
parietal  bone,  while  the  elbows  are  thrown  widely  out 
from  the  sides.  The  knees  are  to  be  separated  eight  or 
ten  inches ;  the  thighs  are  to  be  at  about  right  angles 


with  the  table  ;  thus  the  plane  of  the  table  (<^3),  the 
axis  of  the  thighs  {ac),  and  that  of  the  body  (cb)^  would 
form  a  right-angled  triangle,  of  which  the  thighs  and 
table  would  make  the  right  angle,  and  the  body  the 
hypothenuse.  The  patient  must  be  taught  to  maintain 
unflinchingly  this  position ;  she  must  not  pitch  forwards 
and  make  the  pelvian  angle  (c)  obtuse,  nor  draw  the 
knees  up  under  the  body,  making  it  more  acute  ;  she 
murit  not  arch  the  spine  (cb)  upwards,  for  this  brings 
into  forcible  action  the  abdominal  muscles,  which  should 


14  UTERINE   SURGERY. 

be  perfectly  relaxed,  witli  the  spine  ratlii>r  curved  down 
wards,  as  we  see  it  in  sway-backed  animals.  With  these 
precautions  fully  impressed  on  her,  she  is  to  breathe 
easily,  and  relax  the  muscles  of  the  abdomen.  In  con- 
sequence of  this  position  quietly  retained  for  a  few 
moments,  the  movable  abdominal  and  pelvic  viscera 
necessarily  gravitate  towards  the  epigastrium.  Now,  if 
the  surgeon  will  get  immediately  behind  his  patient  and 
lay  his  hands  on  the  nates,  and  push  them  gently 
upwards  and  backwards,  taking  care  that  her  position  is 
not  changed,  he  will  see  the  mouth  of  the  vagina  open, 
and  at  the  same  moment  hear  the  air  rush  into  it  with  a 
blowing  or  hissing  sound  ;  and  then  if  he  will,  with  even 
his  finger,  raise  the  perineum  uptotvards  the  os  coccygis, 
he  will  see  the  vagina  distended  like  an  inflated  bladder. 
If,  however,  he  will  use  my  speculum  instead  of  the  fin- 
ger, the  cavity  of  the  vagina  will  be  more  easily  seen. 

If  he  will  now  remove  the  instrument  (or  finger), 
and  allow  the  mouth  of  the  vagina  to  close,  and  then 
if  he  will  let  his  tired  patient  fall  over  on  her  side,  he 
will  have  audible  and  unmistakable  evidence  of  the 
sudden  escape  of  air  from  the  vagina.  In  private  prac- 
tice, even  with  the  patient  on  the  side,  this  is  such  an 
unpleasant  occurrence,  and  so  mortifying  to  a  sensitive 
person,  that  I  generally  keep  a  catheter  by  me,  to  be 
placed  momentarily  in  the  vagina,  that  the  air  may 
escape  noiselessly.  If  we  fail  in  the  above  experiment, 
it  will  be  because  we  have  omitted  some  of  the  condi- 
tions essential  to  success. 

The  object  of  this  speculum  (whether  used  with  the 
patient  on  the  knees  or  on  the  side)  is  to  elevate  the 
perineum  and  to  partially  support  the  posterior  wall  of 
the  vagina ;  the  pressure  of  the  atmosphere  with  the 
gravitation    of  the    viscera    does  the  rest.     All  other 


INTRODUCTION.  ]^R 

specula  act  directly  on  the  walls  of  the  vagina,  which 
they  raechanicallj"  distend.  This  one,  as  a  rule,  touches 
but  a  small  portion  of  the  posterior  wall. 

I  was  led  to  the  invention  of  this  speculum  by  a  sin- 
gular incident.  As  showing  from  what  trifles  important 
results  sometimes  spring,  I  venture  to  record  here  the 
circumstances.  I  feel  the  more  justified  in  this  because 
my  speculum  is  by  some  in  England,  and  by  a  few  on 
the  continent,  called  by  the  name  of  another  man,  who 
had  nothing  to  do  with  it,  except  to  hand  it  to  the  instru- 
ment-makers here  to  be  copied,  and  who  in  their  turn 
have  been  the  uncoi^cious  agents  of  doing  me  a  great 
wrong.  In  December,  1845,  a  lady  was  riding  on  a  pony 
in  the  suburbs  of  the  city  of  Montgomery,  Alabama, 
where  I  then  resided.  It  took  fright  and  suddenly 
jumped  from  under  her — she  fell,  striking  her  pelvis 
on  the  ground.  I  saw  her  soon  afterwards ;  her  suffer- 
ings were  very  severe.  Besides  the  contusions  from  the 
fall,  she  complained  of  rectal  and  vesical  tenesmus.  On 
examination,  I  found  a  complete  retroversion  of  the 
uterus.  I  had  been  taught  by  lectures  and  books  that 
the  best  method  of  reducing  a  recent  luxation  of  this 
organ  was  to  place  the  patient  on  the  knees,  and  then 
act  on  the  uterus  through  the  rectum  and  vagina.  This 
lady,  covered  with  a  sheet,  was  so  placed  across  her  bed. 
I  then  introduced  a  finger  into  the  vagina,  but  effected 
nothing  by  it.  Not  wishing  to  pass  the  finger  into  the 
rectum,  which  is  always  disagreeable,  and  to  be  avoided 
if  possible,  I  introduced  the  middle  and  index  fingers 
together  into  the  vagina,  and  while  I  was  making  eftbrts 
to  replace  the  uterus,  all  at  once  it  happened  that  I 
could  not  touch  the  uterus,  nor  even  the  walls  of  the 
vagina,  and  my  fingers  were  swept  around  in  the  pelvis 
without  touching  or  being  touched  by  anything  except 


1@  UTERINE   SURGERY. 

just  where  they  were  grasped  by  the  mouth  of  the 
vagina.  While  I  was  wondering  what  could  be  the 
cause  of  this  anomaly,  my  patient  said  she  was  relieved 
from  the  symptoms  of  which  she  was  complaining  so 
seriously  but  a  few  moments  before.  As  she  was  re- 
lieved, although  I  did  not  understand  how  it  was  done, 
my  duties  to  her  were  of  course  at  an  end.  She  was 
large  and  heavy  ;  letting  her  go,  I  requested  her  to  lie 
down.  Being  quite  exhausted  from  pain  and  the  unna- 
tural position  in  which  she  had  been  placed,  she  threw 
herself  quickly  down  on  her  side,  when  the  sudden 
escape  of  air  from  the  vagina  gave  a  ready  solution  of 
my  dilemma,  as  well  as  of  the  rationale  of  the  reduction 
of  the  dislocated  uterus,  which  was  now  found  to  be  in 
its  normal  position.  And  what  was  its  rationale  ? 
When  the  patient  was  in  the  position  described,  there 
being  a  natural  tendency  of  the  pelvic  viscera  to 
gravitate  towards  the  epigastric  region,  it  would 
require  no  great  vis  a  tergo  to  produce  the  desired 
result  in  a  recent  case  of  this  kind.  One  finger,  how- 
ever, was  not  long  enough  to  throw  the  organ  up,  nor 
were  the  two  ;  but  Avhen  they  were  both  introduced,  in 
my  varying  manipulations  and  strenuous  eiforts,  the 
hand  was  accidentally  turned  with  its  palm  downwards, 
which  thus  brought  the  broad  dorsal  surface  of  the  two 
parallel  fingers  in  contact  with  the  vulvar  commissure, 
thereby  elevating  the  perineum  and  expanding  the 
sphincter  muscle,  which  allowed  the  air  to  rush  into  the 
vagina  under  the  palmar  surface  of  the  fingers,  where, 
by  its  mechanical  pressure  of  fifteen  pounds  to  the  square 
inch,  this  canal  was  suddenly  dilated  like  a  balloon,  and 
the  uteius  replaced  by  its  joressure  alone.  Having  at 
this  time  a  patient  with  a  vesico- vaginal  fistula,  which  I 
could  not  understand,  I  placed  her  in  the  position  above 


INTRODUCTION".  l^J 

described,  and  used  the  handle  of  a  spoon,  curved  at 
right  angles,  to  open  the  vagina,  elevate  the  perineum, 
and  allow  the  air  to  enter,  which  afforded  me  a  complete 
view,  not  onl}^  of  the  fistula,  but  of  the  whole  vagina  ; 
whereupon  this  instrument  (page  11,  fig.  2)  was  a  self- 
suggested  affiiir. 

During  my  residence  in  Alabama,  up  to  1853,  I  had 
no  need  of  any  better  form  of  instrument,  or  any  other 
position  for  its  application  than  that  above  described ; 
but  when  I  went  to  New  York,  a  larger  field  of  obser- 
vation soon  proved  to  me  that  it  was  essential  to  modify 
both  instrument  and  position,  if  they  were  to  be  used  in 
the  every-day  treatment  of  the  ordinary  affections  of  the 
uterus  ;  for  while  a  patient  afflicted  with  such  a  terrible 
infirmity  as  vesico- vaginal  fistula  is  ready  and  willing 
to  be  placed  in  any  position,  however  fatiguing,  a 
moment's  reflection  will  show  that  this  kneeling  posture 
would  be  quite  out  of  the  question  in  the  treatment  of 
the  simple  forms  of  uterine  disease,  as  they  occur  in  the 
higher  grades  of  life. 

With  this  necessity  before  me,  I  went  to  work  to 
improve  my  speculum,  and  at  the  same  time  I  discovered 
that  it  could  be  used  as  efficiently  with  the  patient  on 
the  left  side  as  on  the  knees.  For  nearly  twenty  years  T 
have  used  no  other  speculum,  and  whenever,  in  these 
pages,  I  have  occasion  to  speak  of  the  speculum,  let  it  be 
remembered  that  I  allude  always  and  only  to  this  one  (fig. 
5),  with  the  patient  necessarily  on  the  left  side.  It  is  the 
best  speculum  for  any  purpose,  whether  it  be  for  the 
application  of  the  simplest  dressing,  or  for  the  execution 
of  the  most  difficult  operation. 

I  must  of  course  make  an  exception  in  favour  of  the 
conical  ivory  speculum,  whenever  it  is  necessary  to  apply 
the  hot  iron,  a  thing  rarely  done  in  America. 

2 


18 


UTERINE  SURGERY. 


The  speculum  is  univalve  or  duck-billed,  as  some 
have  called  it.  For  the  sake  of  convenience,  two  spe- 
cula of  unequal  sizes  are  attached  to  the  same  handle,  one 


Fig.  5. 


at  each  extremity.  This  handle  may  be  slightly  bent, 
as  seen  in  fig.  5,  or  it  may  be  perfectly  straight,  as  I  for- 
merly used  it  (fig.  2).  The  only  object  in  the  slight 
curvature  is  to  facilitate  its  leverage  in  prolonged  opera- 
tions. The  assistant  may  become  tired  of  holding  on  to 
the  distal  end,  and  then  it  is  a  great  relief  to  grasp  the 
shaft  in  the  middle,  where  it  is  gently  curved.  The 
object  of  having  two  blades  or  specula  to  one  shaft  is 
merely  to  have  them  of  different  sizes  so  as  to  suit  dififerent 
vaginas  ;  for  there  are  no  two  vaginas  exactly  alike, 
any  more  than  there  are  two  faces  precisely  alike. 


INTRODUCTION. 


19 


1  have  one  witli  a  blade  six  inclies  long,  another  but 
two  inches,  and  another  of  the  ordinary  length,  an  inch 
and  three  quarters  wide.  But  these  sizes  are  very  rarely 
needed.  For  ordinary  purposes,  two  instruments,  i.e. 
four  blades,  are  all  that  we  need. 

The  smallest  I  call  the  virgin  speculum ;  for  unhap- 
pily we  are  sometimes  compelled  to  use  a  speculum  on 
the  unmarried,  and  then  it  is  proper  to  have  it  of  such  a 
suitable  size  as  not  to  give  j^ain,  and  not  to  injure  the 
hymen.  Here  one  blade  is  a  little  less  than  three  inches 
long,  the  other  a  fraction  over ;  the  first  three-quarters 
of  an  inch  wide,  the  other  seven-eighths.  But  the  specu- 
lum for  ordinary  use  on  the  married  has  the  smaller 
blade  about  three  and  a  half  inches  long,  by  about  one 
inch  wide.  This  is  the  one  that  we  need  in  nine  cases 
out  of  ten. 

The  other,  or  larger  one,  is  about  four  inches  long  by 
an  inch  and  a  quarter  wide.  This  will  be  needed  where 
the  vagina  is  very  large.  As  said  before,  they  are  made 
much  wid^r ;  but  they  are  then  apt  to  produce  j)ain, 
a  thing  always  to  be  avoided. 

In  all  vaginal  examinations,  it  matters  not  for  what 
purpose,  a  speculum  should  never  be  used  till  we  have 
by  the  touch  first  and  fully  ascertained  the  condition  of 
the  uterus  and  its  appendages. 

This  injunction  is  particularly  imperative,  and  for  the 
most  obvious  reasons.  1st,  because  the  size  of  the  spe- 
culum should  be  always  adapted  to  the  capacity  of  the 
vagina ;  a  small  speculum  in  a  large  vagina  is  compa- 
ratively useless  ;  on  the  contrary,  a  large  speculum  in 
a  small  vagina  is  cruelly  painful.  2nd,  because  it  should 
be  passed  in  the  direction  of  the  axis  of  the  vagina, 
taking  care  not  to  strike  it  against  the  cervix  uteri,  par- 
ticularly if  this  be  the  seat  of  granular  erosion,  of  poly- 


20  giBRINB    SURGERY. 

pus,  of  cauliflower  excrescence,  or  other  hsemorrhaglc 
disease,  all  of  which  should  be  previously  ascertained  by 
the  touch. 

It  has  been  objected  to  this  speculum,  that  its  use 
requires  the  assistance  of  a  third  person.  Apart  from 
its  real  value,  there  could  be  no  stronger  reason  for 
its  universal  adoption.  I  insist  that  a  third  person 
should  always  be  present  on  such  occasions.  Delicacy 
and  propriety  require  it,  and  public  opinion  ought  to 
demand  it.  I  do  not  mean  lay,  but  professional  public 
opinion. 

I  am  sure  that  I  never  made  a  vaginal  examination, 
or  used  a  speculum  a  dozen  times  in  my  life  without  the 
presence  of  a  third  person.  I  have  never  had  a  patient 
to  object  who  was  educated  or  sensible  ;  but  the  silliest 
person  would  see  the  necessity  of  it  when  told  that  pro- 
priety required  it,  even  if  an  assistant  were  not  neces- 
sary. The  few  that  have  objected  to  the  presence  of 
another  person  in  the  room  at  the  time  of  a  speculum 
examination,  have  done  so  from  the  fear  of  personal 
exposure.  We  are  too  apt  to  disregard  this  innate  feel- 
ing of  delicacy  when  we  have  been  much  used  to  hos- 
pital practice  ;  but  we  can  never  make  a  mistake  if 
we  always  cultivate  the  same  gentleness  and  kindness 
towards  the  poorest  hospital  patient  that  we  would  use 
towards  the  highest  princess.  I  repeat,  then,  that  we 
should  never  in  our  examinations  allow  any  exposure  of 
person,  not  even  in  hospital  practice.  When  the  touch 
is  made,  there  can  be  none,  of  course,  with  the  patient 
on  the  back,  and  covered  with  a  sheet.  When  the  spe- 
culum is  used,  we  should  see  only  the  neck  of  the  womb 
and  the  canal  of  the  vagina. 

I  have  said  that  for  a  speculum  examination  there  is 
nothing  better  than  a  table   covered  with  a  quilt  or 


INTRODUCTION. 


21 


blankets  folded,  and  this  is  literally  true  ;  but  for  the 
consultation-room  I  have  a  chair  which  has  served  such 
a  good  purpose  that  I  introduce  it  here,  that  others  may 
profit  by  it. 

Some  twelve  or  fifteen  years  ago,  Mr.  James  Holmes, 
of  Charleston,  S.C.,  was  driven  to  the  necessity  of  invent- 
ing what  he  called  an  "  Invalid  Chair.  The  patient 
sitting  in  this  chair  (fig.  6),  can  with  the  greatest  ease 


Fig.  G. 


and  without  an  effort  poise  the  body  for  any  length  of 
time,  at  any  angle  between  the  erect  and  horizontal 
postures.  Mr.  Holmes  invented  this  chair  especially 
for  a  near  relative  of  his,  who  sufi^ared  from  prolonged 
attacks  of  (I  believe)  gout  or  some  other  very  painful 
affection.  It  is  much  used  in  America,  and  was  even 
introduced  on  some  lines  of  railway  as  a  sleeping-chair. 
I  am  thus  minute,  because  I  do  not  wish  to  claim  it  as 
mine.  To  adapt  it  to  my  own  practice  I  had  it  made 
24  inches  wide  ius::ead  of  IS,  and  30  inches  high  iustead 


22 


UTERINE   SURaERY. 


of  22.  I  liave  added  legs  or  uprights,  a^  a,  to  support 
the  lower  part  of  the  chair  when  it  is  extended  in  the 
form  of  an  operating-table  (fig.  7).  There  is  also  an 
elastic  cord,  ^,  to  pull  these  uprights  back  under  the 
chair  when  it  is  changed  from  a  table  to  a  mere  chair 
again.     For  all  practical  purposes  it  is  really  no  better, 


Fig.  1. 


as  before  said,  than  a  common  table ;  but  any  patient 
would  sit  in  the  chair  without  nervous  ao^itation,  while 
some  become  greatly  alarmed  at  being  requested  to 
mount  a  table.  The  patient  once  seated,  is  told  that  the 
chair  is  only  a  couch,  and  she  is  requested  to  lean  back 
and  extend  it  horizontally  by  her  own  weight,  with 
perhaps  a  little  assistance  from  the  nurse  who  stands  at 
the  back  of  the  chair.  I  am  almost  afraid  to  write 
these  little  things,  but  I  do  it  only  for  my  younger 
brethren,  who  may  need  to  learn  the  importance  of 
educating  their  patients  to  feel  that  everything  is  being 
done  that  delicacy  and  propriety  require  on  an  occasion 
so  trying  to  a  sensitive  nature. 

When  the  patient  lies  back  and.  the  chair  is  extended 
in  the  form  of  a  table,  it  will  be  necessary  to  draw  the 


INTRODUCTION. 


23 


person  down  to  tlie  lower  edge  of  it,  c  <?,  whether  for 
a  digital  or  speculum  examination.  Afterwards  the 
patient  moves  again  up  on  the  centre  or  seat  of  the 
chair,  the  uprights,  «,  a^  are  drawn  back,  and  the  chair 
almost  voluntarily  assumes  its  proper  form. 

For  a  speculum  examination  the  patient  is  to  lie  on 
the  left  side.  The  thighs  are  to  be  flexed  at  about  right 
angles  with  the  pelvis,  the  right  being  drawn  up  a  little 
more  than  the  left.  The  left  arm  is  thrown  behind 
across  the  back,  and  the  chest  rotated  forwards,  bringing 
the  sternum  very  nearly  in  contact  with  the  table,  while 
the  spine  is  fully  extended,  with  the  head  resting  on  the 
left  parietal  bone.  The  head  must  not  be  flexed  on  the 
sternum  nor  the  right  shoulder  elevated.  Indeed,  the 
position  must  simulate  that    on  the  knees  as   much  as 


Fig.  8. 


possible,  and  for  this  reason  the  patient  is  rolled  over  on 
the  front,  making  it  a  left  lateral  semiprone  position. 
The  nurse  or  assistant  standing  at  her  back  pulls  up  the 


24  UTERINE  SURGERY. 

riglit  side  of  the  nates  with  the  left  hand,  when  the 
surgeon  introduces  the  speculum,  elevates  the  perineum, 
and  gives  the  instrument  into  the  right  hand  of  the 
assistant,  who  holds  it  firmly  in  the  desired  position. 

The  introduction  of  the  speculum  is  a  matter  of 
some  importance.  It  is  done  under  cover,  with  the 
right  index  finger  as  a  guide,  as  seen  in  fig.  8.  The 
object  of  this  is  to  prevent  the  point  of  the  instrument 
from  striking  against  the  cervix  uteri. 
The  finger  is  not  to  be  withdrawn  till 
we  are  sure  that  the  end  of  the  sj^eculum 
has  passed  beyond  the  cervix,  or  is  well 
turned  back  towards  the  rectum.  If 
the  patient  breathes  easily,  the  vagina 
will  be  immediately  distended  by  the 
pressure  of  the  atmosphere,  so  as  to 
bring  the  neck  of  the  uterus,  the  pos- 
terior cul-de-sac,  and  the  whole  of  the 
anterior  wall  of  the  vagina  into  view, 
without  the  least  traction,  pressure,  or 
suffering.  But  if  she  is  alarmed  and 
breathes  hurriedly,  or  bears  down,  it 
will  be  otherwise.  If  the  uterus  be 
retroverted,  the  os  tincse  is  easily  seen. 
If  it  be  in  a  normal  position,  there  is  no 
trouble  in  getting  a  good  view  of  it ; 
but  if  it  be  completely  ante  verted,  with 
a  narrow  vagina,  then  it  will  be  neces- 
sary to  hook  a  small  tenaculum  into  the 
anterior  lip,  and  pull  it  gently  forwards, 
as  shown  in  fig.  14,  where  the  manner 
of  introducing  the  sponge-tent  is  illus-  y^^io. 
trated.  The  tenaculum  is  to  be  slightly 
inserted  into  the  mucous  membrane.     It  gives  no  pain^ 


INTRODUCTION.  25 

and  produces  no  bleeding,  unless  there  is  great  engorge- 
ment ;  but  even  then  it  amounts  to  nothing.  Another 
plan  of  bringing  the  os  tincse  into  view  is  to  draw  the 
neck  forwards  by  pressure  in  the  anterior  cul-de-sac 
with  this 'instrument  (fig.  10),  which  I  call  the  uterine 
depressor. 

I  have  never  known  any  one  accustomed  to  this 
method  and  these  instruments  who  was  willing  to  revert 
to  the  old  plan. 

The  consideration  of  other  means  of  exploration, 
such  as  the  sound,  tent,  <fec.,  I  leave  till  we  come  to 
speak  of  treatment. 


SECTION  I. 


CONCEPTION    OCCURS    ONLY   DURING  MENSTRUAIi 

LIFE. 


SECTION   I. 

CIONCEPTION    OOOURS    ONLY    DURINa   MENSTRUAL    LIFE. 

This  is  so  self-evident,  that  it  might  be  passed  without 
further  notice.  I  do  not  know  that  conception  has  ever 
occuri'ed  previously  to  the  appearance  of  the  menstrual 
flow.  Cases  are  recorded  where  it  happened  at  a  very 
tender  age  ;  but  it  was  always  preceded  by  the  appear- 
ance of  the  function  that  we  are  taught  to  look  upon  as 
evidence  of  the  fitness  for  conception.  As  an  example, 
I  may  cite  the  following,  which  is  perfectly  authentic. 

Dr.  Curtis,  of  Boston,  examined  into  the  particulars 
of  a  case  of  early  pregnancy  that  occurred  in  the  poor- 
house  of  that  city,  and  reported  "  that  the  girl  Elizabeth 
Drayton  became  pregnant  twenty-four  days  before  she 
was  ten  years  old,  and  was  delivered  of  a  fine,  full-grown 
male  child,  weighing  fully  eight  pounds,  when  she  was 
ten  years  eight  months  and  seven  days  old.  The  reputed 
father  of  the  child  is  said  to  be  about  fifteen  years  of 
age.  The  mother  menstruated  once  or  twice  before 
concej)tion,  was  tolerably  healthy  during  gestation,  and 
had  rather  a  lingering  but  quite  natural  labour."  * 

Conception  has  occurred  at  an  advanced  period,  and 
even  after  a  supposed  change  of  life. 

An  instance  of  this  sort  fell  under  my  observation 
in  the  state  of  Alabama,  in  1840,  where  an  old  negro 
woman  (said  to  be  58  or  60)  became  a  mother,  after 


*  Medical  Times  and   Gazette,  April,    1863,  from  the  Boston  Medical 
Journal^  February  19th,  1863. 


30  UTERINE  SURGERY 

having  ceased  to  have  children  for  more  than  twenty 
years. 

I  regret  exceedingly  that  I  did  not  investigate  this 
case  more  minutely,  but  in  my  younger  days  I  did  not 
feel  much  interest  in  the  subject.  But  I  now  know  of 
two  well-authenticated  cases  of  parturition  at  the  age 
of  fifty-two. 

Many  women  conceive  without  menstruating,  but 
it  is  always  during  menstrual  life.  Most  accoucheurs 
have  doubtless  met  with  such  cases. 

I  know  a  lady  some  36  or  38  years  old,  who  is  the 
mother  of  six  children,  three  of  whom  were  born  (at 
single  births)  without  the  least  sign  of  intermediate 
menstruation.  She  menstruated  soon  after  marriage, 
immediately  conceived,  was  safely  delivered  at  term, 
and  while  nursing  found  herself  pregnant  again;  she 
then  weaned  her  child,  went  the  full  term  with  the 
second,  was  fortunately  delivered  ;  and  while  suckling 
it,  became  pregnant  a  third  time.  She  thus  bid  fair 
to  have  a  large  family  very  rapidly,  but  unfortunately, 
after  her  third  confinement,  she  got  some  uterine 
disease  that  arrested  her  child-bearing  for  several 
years. 

Dr.  Emmet  and  myself  saw  a  case  still  more  remark- 
able than  this  in  1859.  One  of  the  patronesses  of  the 
Woman's  Hospital  requested  me  to  visit  a  poor  woman, 
a  'protegee  of  hers,  who  was  supposed  to  have  ovarian 
dropsy,  which  had  increased  so  rapidly  that  she  appre- 
hended an  early  fatal  result.  On  visiting  the  patient, 
she  told  me  that  the  tumour  began  to  grow  not  very 
long  after  the  birth  of  her  last  and  eighth  child,  which 
was  now  some  twelve  or  thirteen  months  old.  She  was 
still  suckling  it,  and  it  seemed  to  be  drawing  her  very 
life  out  of  her.     She  was  in  bed,  greatly  prostrated  from 


CONCEPTION  OCCURS  ONLY  DTOING  MENSTRUAL  LIFE.      3| 

want  of  proper  and  sufficient  nourishment,  and  from 
the  exhaustion  of  super-lactation,  all  of  which  had 
been  supposed  to  belong  to  the  rapid  growth  of  the 
tumour.  Laying  my  hands  on  the  abdomen  for  pal- 
pation, I  instantly  detected  foetal  movement.  I  asked 
her  if  she  suspected  pregnancy  ;  she  said  no,  nor  had 
she  felt  any  quickening,  although  the  movements  of  the 
child  were  by  no  means  feeble.  The  touch  showed  the 
mouth  of  the  womb  dilated  fully  two  inches,  with  the 
head  presenting.  Labour  set  in  the  next  day,  and  she 
was  happily  delivered  by  Dr.  Emmet  of  a  fine  vigorous 
child.  This  was  her  ninth  labour  in  fourteen  or  fifteen 
years ;  and  she  told  Dr.  Emmet,  that  during  the  whole 
of  her  married  life  she  had  menstruated  but  three  times  ; 
thus,  notwithstanding  the  accepted  views  of  the  profes- 
sion in  regard  to  the  relation  of  menstruation  to  concep- 
tion, we  find  anomalies,  which,  however,  are  so  rare  that 
they  do  not  invalidate  the  rule. 

It  is  a  little  curious  that  a  woman  should  have  had 
eight  pregnancies,  and  have  gone  the  full  term  of  the 
ninth,  without  the  least  consciousness  of  a  movement  of 
the  foetus. 

But  there  was  evidently  no  malingering,  for  she  was 
immediately  raised  from  the  deepest  despair  to  the 
greatest  joy,  when  her  tumour  was  pronounced  to  be 
a  living  child  to  be  born  in  a  few  hours.  I  have  seen 
several  cases  of  pregnancy  where  the  mothers  were 
totally  unconscious  of  any  movement  on  the  part  of  the 
child.  I  allude  to  this  as  a  subject  of  interest  to  the 
profession  at  large  ;  for  an  error  in  diagnosis,  whether 
in  failing  to  detect  pregnancy  when  it  exists,  or  in 
asserting  it  where  it  does  not  exist,  always  injures  us  as 
a  body,  and  sometimes  inflicts  injury  on  the  subjects  of 
our  mistakes. 


32  uterTSte  surgery. 

A  lady,  married  about  twenty-three  years,  and  child- 
less, became  irregular  at  forty-three.  Her  physicians 
said  it  was  incipient  change  of  life,  which  was  doubtless 
true.  After  a  few  months  of  irregularity,  the  menses 
ceased  entirely.  With  this  change  many  women  antici- 
pate evil  in  some  form  or  othei*.  This  poor  sufferer 
expected  cancer,  but  instead  of  that  her  physicians 
detected  a  pelvic  tumour.  She  was  plied  with  iodine 
for  a  long  time,  and  had  flying  blisters  alternately  over 
the  iliac  regions ;  but  in  spite  of  the  most  active  means 
the  tumour  continued  to  grow.  Her  case  was  considered 
hopeless,  and  it  was  thought  advisable  for  her  to  return 
to  the  place  of  her  nativity  to  die  amongst  her  friends. 
On  her  arrival  in  New  York  she  patiently  resigned  her- 
self to  her  fate,  and  made  all  arrangements  for  her 
approaching  dissolution.  After  waiting  a  month  in 
vain,  some  of  her  fiiends  persuaded  her  to  have  other 
medical  advice,  and  I  saw  her.  There  was  not  the 
shghtest  difficulty  in  detecting  foetal  movement  and 
foetal  pulsation,  and  when  I  told  her  that  in  two  weeks 
she  would  need  baby-clothes  instead  of  a  shroud,  and  a 
cradle  instead  of  a  coffin,  she  could  not  believe  it. 
During  the  whole  of  her  pregnancy  she  was  not  conscious 
of  any  motion. 

Here  the  mistake  was  fraught  not  only  with  damage 
to  the  profession,  but  with  loss  to  the  husband,  for, 
engaged  in  a  profitable  business,  he  was  compelled  to 
sell  it  off  at  a  sacrifice,  and  to  make  a  long  journey  to 
New  York,  when  he  should  have  remained  at  home.  I 
have  seen  many  similar  mistakes,  and  that  too  since  the 
days  of  Dr.  Kennedy's  beautiful  work  on  Obstetric 
Auscultation.  *     We  may  be  in  doubt  about  any  case  up 

*  "  Observations  on    Obstetric  Auscultation  ;  with    Analysis  of  the 


CONCEPTIOIf  OCCURS  ONLY  DURING  MENSTRUAL  LIFE.         33 

to  the  fifth  month  of  pregnancy,  but  never  after  that ; 
for  then  the  beating  of  the  foetal  heart  will  infallibly 
guide  our  judgment.  Dr.  Routh,*  of  the  Samaritan 
Hospital,  has  detected  pregnancy  as  early  as  from  the 
sixth  to  the  thirteenth  week  by  means  of  his  vagino- 
scope, which,  coming  directly  in  contact  with  the  cervix 
uteri,  gives  an  earlier  indication  of  the  placental  souffle 
than  we  could  get  by  the  stethoscope. 

Mistakes  sometimes  occur  in  the  hands  of  the  best 
men  in  the  profession,  and  then  it  is  the  result  wholly  of 
carelessness.  For  example,  a  lady,  thirty-five  years  old, 
the  mother  of  several  children,  had  a  small  fibroid 
tumour  on  one  side  of  the  womb.  Her  physician,  a  most 
accomplished  diagnostician,  watched  the  progress  of  this 
tumour,  which  seemed  to  be  stationary  for  a  long  time. 
I  should  remark  that  from  the  time  the  tumour  was 
observed,  the  patient  ceased  to  have  children.  And  so 
things  went  on  for  five  or  six  years,  when  the  abdomen 
began  to  enlarge,  and  as  we  sometimes  see  in  ovarian 
tumours,  the  menses  ceased.  The  physician  put  her  on 
bromide  of  potassium  internally,  and  tincture  of  iodine 
externally.  In  spite  of  this  the  tumour  continued  to 
enlarge,  and  her  physician  brought  her  from  a  neigh- 
bouring city  to  me.  I  had  only  to  lay  my  hands  on  the 
abdomen  to  detect  motion,  and  with  the  stethoscope  the 
foetal  heart  was  easily  heard.  Now,  here  the  physician, 
having  his  mind  full  of  the  fibroid  growth  from  which  he 
had  so  long  anticipated  evil,  never  made  any  thorough 


Evidences  of  Pregnancy  ;  and  an  Inquiry  into  the  Proofs  of  the  Life  and 
Death  of  the  Foetus  in  Utero."  By  Every  Kennedy,  M.D,,  &c.  Dublin  : 
Hodges  &  Smith.     1833. 

*  "  On  Some  of  the  Symptoms  o^  Early  Pregnancy."    By  C.  IT.  F. 
Routh,  M.D.,  &c.     London  :  T.  Richards.     1864.    Pp.  21. 

3 


34  UTERINE  SURGERY. 

investigation  of  the  case  after  the  abdomen  began  to 
enlarge,  and.  the  patient,  who  was  a  most  intelligent 
woman,  declared  she  had  not  for  a  moment  suspected 
pregnancy,  and  that  she  had  not  experienced  the  slightest 
sensation  of  motion. 

While  -on  this  subject,  I  may  mention  an  opposite 
class  of  cases  in  which  we  occasionally  make  grave 
mistakes.  A  hysterical  sterile  woman,  naturally  anxious 
for  offspring,  imagines  herself  pregnant,  denies  that 
she  menstruates,  affects  a  quickening,  seems  to  grow 
larger  and  larger,  till  at  last  the  fulness  of  time  arrives ; 
she  goes  to  bed,  and  has  some  irregular  colicky  pains ; 
but  nothing  more.  This  is  a  case  of  hysterical  mono- 
mania, for  which  no  physician  could  be  responsible ;  but 
if  called  to  give  an  opinion,  he  should  be  careful  not  to 
be  misled  by  the  artful  misrepresentations  of  a  "  mind 
diseased."  Young  women  sometimes  honestly  imagine 
themselves  pregnant,  and  2:>hysicians,  I  am  sorry  to  say, 
are  occasionally  deluded  into  the  support  of  their  whim, 
notwithstandino:  the  fact  that  menstruation  returns  reffu- 
larly  every  twenty-eight  days,  and  pursues  its  usual 
course. 

An  example  of  this  sort  occurred  at  Baden-Baden  a 
few  years  ago,  under  the  care  of  a  very  eminent  physi- 
cian, now  dead,  who  allowed  his  patient  to  lie  in  bed  for 
nine  mouths  to  prevent  a  miscarriage,  when  in  fact  she 
menstruated  regularly  during  the  whole  time.  At  the 
end  -of  the  tenth  month  another  physician  was  called  in, 
who  said  the  lady  had  never  been  pregnant  at  all. 

But  while  many  women  go  through  pregnancy  with- 
out feeling  the  slightest  motion  of  the  foetus,  a  very 
opposite  state  of  things  is  occasionally  met  with  about 
the  time  of  change  of  life.  A  woman,  forty  years  of  age 
or  more,  becomes  irregular ;  she  thinks  herself  pregnant ; 


CONCEPTION  OCCURS  ONLY  DURING  MENSTRUAL  LIFE.        35 

by-and-by,  she  quickens ;  she  begins  to  make  baby- 
clothes  ;  she  tells  her  intimate  friends  of  her  interesting 
condition  ;  she  gradually  grows  larger ;  the  time  for 
confinement  arrives ;  she  is  not  quite  as  large  as  in  her 
former  pregnancies  ;  nevertheless  she  cannot  be  deceived, 
for  the  frequent  regular  movements  of  the  foetus  make  it 
impossible  for  her  to  be  otherwise  than  pregnant.  At 
last  she  becomes  alarmed  at  the  procrastination  of  the 
labour,  and  sends  for  her  physician,  who  finds  the  abdo- 
men large,  but  the  enlargement  is  due  to  an  immense 
deposit  of  adipose  tissue  in  its  parietes.  He  passes  his 
finger  into  the  vagina,  and  discovers  the  uterus  in  an 
unimpregnated  state  ;  indeed,  it  may  be  smaller  than 
usual,  for  the  cervix  may  be  found  rather  atrophied,  and 
the  whole  organ  gradually  undergoing  the  change  that 
we  always  see  when  change  of  life  occurs. 

I  have  seen  several  cases  of  this  false  quickening, 
never  in  a  woman  under  thirty-eight,  nor  over  forty-eight. 
They  had  all  borne  children,  and  all  had  a  tendency 
to  embonpoint.  They  were  all  women  of  culture,  refine- 
ment, and  of  good  common  sense  ;  and  so  strong  in 
every  case  was  the  mental  impression  of  the  sense  of 
quickening,  that  it  was  impossible  to  convince  them  that 
there  was  no  pregnancy.  Two  of  these  ladies  returned 
to  me  several  times  in  the  course  of  a  year,  and  insisted 
that  I  must  be  mistaken.  I  now  regret  having  dismissed 
them  so  perem^^torily,  as  I  thereby  lost  the  opportunity 
of  w^atching  the  progress  and  termination  of  this  freak 
of  change  of  life. 


SECTION  II. 


MENSTRUATION   SHOULD  BE  SUCH  AS  TO  SHOW   A 
'    HEALTHY  CONDITION  OF  THE  UTERINE  CAVITY, 


SECTION    II. 

MENSTRUATION    SHOULD    BE    SUCH  AS   TO    SHOW  A  HEALlHr 
CONDITION  OF  THE  UTERINE  CAVITY. 

Of  Scanty  Menstruation. — If  asked  what  constitutes 
normal  menstruation,  I  should  reply,  a  painless  uncoagu- 
lated  flow,  returning  at  intervals  of  about  four  weeks, 
lasting  three,  four,  five,  or  six  days,  and  requiring  the 
use  of  not  more  than  three,  or,  at  the  farthest,  four 
napkins  in  the  twenty-four  hours.  It  may  vary  from  a 
healthy  standard  in  both  quantity  and  quality.  It  may 
be  scanty  or  profuse,  and  painful  or  not,  without  regard 
to  quantity.  If  the  flow  falls  short  of  three  days'  dura- 
tion, it  may  be  called  scanty.  If  it  continues  longer 
than  six  or  seven  days,  it  may  be  profuse,  but  not  alwa3^s 
so.  It  may  be  very  abundant,  and  last  but  two  or  three 
days  ;  and,  again,  it  may  continue  twelve  or  fifteen  days, 
and  be  very  scanty,  requiring  not  more  than  one  napkin 
in  the  twenty-four  hours.  The  explanation  of  eitlier  of 
these  conditions  will  generally  be  found  in  some  organic 
deviation  from  a  normal  state. 

Conception  may  take  place,  whether  the  menstrua- 
tion be  scanty  or  profuse.  But  either  extreme  is  not 
very  favourable  to  it,  not  that  the  amount  of  blood  lost 
IS  per  se  an  important  mattei',  except  as  the  index  of  an 
organic  condition,  fjivourable  or  otherwise  to  the  fulfil- 
ment of  this  great  law  of  nature. 

According  to  modern  views,  the  menstrual  fluid  is  not 
a  secretion,  but  an  exudation  of  blood  from  the  lining 
membrane  of  the  cavity  of  the  uterus,  which  acquires 


40  UTERINE    SURGERY. 

its  peculiar  qualities  by  admixture  with  the  secretions 
of  the  cervix  and  vagina  as  it  passes  outwards. 

We  often  see  menstruation  so  scanty,  that  it  lasts  but 
a  day,  or  a  day  and  a  half,  one  napkin  having  perhaps 
sufficed  for  the  whole  time.  Under  such  circumstances, 
it  has  been  supposed  that  there  is  defective  ovulation  ; 
but  this,  of  course,  is  mere  hypothesis,  for  it  may  or  may 
not  be  so.  It  must  be  admitted,  however,  that  menstrua- 
tion is  a  sign  of  ovulation,  the  one  taking  place  when 
the  other  begins,  and  ceasing  when  it  stops.  With 
ovulation,  we  see  the  uterus  suddenly  developed  in  size, 
the  fit  receptacle  of  a  new  being.  With  change  of  life 
we  see  it  gradually  returning  to  the  diminutive  propor- 
tions that  it  had  before  puberty. 

In  habitually  scanty  menstruation,  if  the  patient  has 
never  borne  children,  we  shall  generally  find  the  uterus 
smaller  than  usual,  with  rather  a  long,  pointed,  indurated 
cervix,  and  if  so  the  os  and  cervical  canal  will  necessarily 
be  small.  On  the  contrary,  if  the  patient  has  borne 
children,  the  uterus  may  be  larger  than  natural;  but 
the  history  of  the  case  will  probably  show  that  there 
has  been  some  puerperal  trouble  of  an  inflammatory 
character,  resulting  in  imperfect  involution  of  the  organ. 
In  either  case  I  have  not  derived  the  benefit  that  I  had 
expected  from  surgical  means,  such  as  a  cupping  pump 
to  the  cervix,  suction  and  laceration  of  the  lining  mem- 
brane of  the  uterine  cavity,  and  the  intra-uterine 
galvanic  pessary  of  Professor  Simpson,  which  seems  to 
have  produced  very  good  results  in  his  experienced 
hands,  and  also  in  those  of  his  pupil,  Professor  Priestly, 
of  King's  College  Hospital. 

For  the  general  management  of  this  class  of  cases,  I 
must  refer  the  student  to  our  systematic  works  (Chur- 
chill, West,  Hewitt,  ^c,  &c.),  and  at  the  same  time  he 


OF  MENSTRUATION.  4| 

should  not  neglect  Faradization,  as  tauglit  and  practised 
by  Althaus,*  of  London,  and  Dachennef  (de  Boulogne), 
of  Paris.  Nor  should  he  fail  to  study  the  brief  mono- 
graph of  Dr.  Chapman,J  on  cold  and  heat  in  the  treat- 
ment of  the  functional  diseases  of  women. 

It  is  now  pretty  well  understood  that  electricity 
judiciously  administered  is  especially  valuable  as  an 
emmenagogue  in  young  women,  where  the  menstrual 
function  has  not  yet  been  fully  established,  in  conse- 
quence of  a  torpid  state  of  the  vaso-motor  nerves  of 
the  ovaries  and  uterus  ;  and  it  has  also  proved  successful 
when  the  catamenia  have  been  lost  after  labour,  or  in 
consequence  of  cold  shock  or  mental  anxiety. 

Of  Profuse  Menstruation. — The  profuseness  of 
menstruation  is  to  be  judged  of  not  so  much  by  its 
duration  as  by  the  quantity  of  blood  and  the  effects  of 
its  loss.  Sometimes  it  will  be  very  abundant  from  its 
inception  to  its  termination.  Again,  it  may  be  violent 
for  thirty-six  or  forty-eight  hours,  and  then  moderate  to 
a  normal  standard.  A  very  good  way  to  judge  of  the 
quantity  lost  is  by  the  number  of  napkins  needed 
to  protect  the  person  and  linen.  A  change  of  three 
or  four  napkins  in  the  twenty  four  hours  is  about  a 
proper  number  for  normal  menstruation.  If  seven  or 
eight  be  needed,  the  flow  may  be  called  profuse,  and  if 


*  '•  ATreatise  on  Medical  Electricity,  Theoretical  and  Practical."  By  J. 
Althau?,  M.D.     London.     1859.     Pp.  298. 

t  "  De  rElectrisatiun  Localisee  et  de  son  Application  a  la  Pathologic  et  la 
Therapeutique."  Par  M.  le  Docteur  Duchenne  (de  Boulogne).  Paris. 
Second  Edition.     1861.     Pp.  89. 

X  "  Functional  Diseases  of  Women,"  &c.  By  John  Chapman,  M.I). 
London  :  Trubner  &  Co.     1863. 


42  UTERINE  SURGERY. 

a  dozen  or  more,  theu  it  may  be  called  a   menorrha- 
gia. 

In  tlie  treatment  of  menorrhagia,  we  are  by  no 
means  to  neglect  general  constitutional  remedies.  Some 
bleed,  but  I  never  saw  a  case  in  which  I  thought  this 
practice  justifiable.  All  prescribe  revulsives,  tonics, 
chalybeates,  mineral  acids,  ergot,  tfec,  wliicli  treatment 
is  well  enough  as  far  as  it  goes,  but  does  not  always 
strike  at  the  root  of  the  evil ;  and  often  valuable  time  is 
thus  thrown  away.  I  know  very  well  that  we  may  have 
menorrhagia  from  mere  debility,  from  super-lactation, 
and  from  some  temporary  engorgement  of  the  portal 
circulation ;  but  such  cases  are  not  very  common,  and 
not  usually  obstinate.  If  there  is  anything  abnormal 
in  the  quantity  of  blood  lost  at  the  menstrual  epoch, 
there  is  always  a  cause  for  it,  and  we  shall  generally 
be  able  to  find  it  out  by  directing  our  attention  to  the 
seat  and  source  of  the  trouble.  If  the  nose  bleeds,  we 
try  to  stop  it  by  the  most  direct  methods  in  our  power. 
If  the  hemorrhoidal  vessels  bleed  persistently,  we  attack 
them  with  the  ecraseui\  ligatures,  nitric  acid,  persulphate 
or  perchloride  of  iron.  Why,  then,  should  we  permit 
the  womb  to  lose  an  unnatural  quantity  of  blood  without 
at  once  interrogating  it  on  the  subject  ?  I  would  not 
ignore  such  general  means  as  we  all  admit  to  be  avail- 
able, but  I  would  never  put  off  a  uterine  exploration  in 
any  confirmed  case  of  abnormal  flow  ;  for  where  there  is 
an  inveterate  menorrhagia,  there  will  always  be  some 
organic  cause  for  it.  It  may  be  due  simply  to  granular 
erosion  ;  to  engorgement  of  the  cervix  ;  to  fungoid 
granulations  in  the  cervical  canal,  or  in  the  uterine 
cavity;  to  polypi  of  the  os,  the  cervix,  or  the  cavity; 
to  a  fibroid  tumour,  intra-uterine  or  intra-mural  ;  to 
inversion  of  the   uterus,  to  hsematocele ;  or  it   may  be 


OF  MENSTRUATION.  ^3 

a  sign  of  some  malignant  degeneration,  all  giving  rise  to 
hemorrhage,  and  each  requiring  its  own  peculiar  and 
appropriate  management. 

I  propose  to  illustrate,  from  clinical  experience,  the 
surgical  treatment  of  menorrhagia  as  it  may  originate 
from  one  or  the  other  of  these  sources.     And  first, — 

Of  MejS^orehagia  from  Graintulae  Erosioist. — One 
example  of  this  will  suffice.  Mrs. ,  aged  twenty- 
eight,  of  leuco-phlegmatic  temperament,  confined  four 
years  and  a  half  ago,  never  well  since,  was  greatly 
exhausted  by  lactation,  and  weaned  her  child  at  six 
months,  had  very  profuse  menstruation,  lasting  eight 
days,  some  leucorrhoea,  pelvic  pains,  dysuria,  <fec. — could 
not  walk  at  all — had  to  be  carried  up  and  down-stairs — 
was  quite  anaemic  and  exhausted,  irritable,  peevish, 
hysterical,  crying  easily  and  at  trifles — had  had  the 
usual  constitutional  and  tonic  treatment  from  several 
physicians  without  improvement — the  uterus  in  proper 
position  was  larger  than  natural — the  edges  of  the  os 
were  covered  with  luxuriant  granular  erosions,  which 
could  be  seen  extending  up  the  canal  of  the  cervix.  To 
these  granulations  I  applied  chromic  acid,  which  is  with 
me  a  favourite  escharotic.  It  is  more  powerful  than  the 
nitrate  of  silver,  and  ordinarily  perfectly  painless.  It  is 
used  thus  : — Take  a  drachm  of  the  salt,  which  is  very 
deliquescent,  and  add  slowly  a  drachm  of  distilled  water ; 
the  salt  is  instantly  dissolved  and  ready  for  use.  Dip  a 
small,  pointed,  solid  glass  rod  in  the  solution,  let  it  not 
take  up  more  than  a  drop  or  two,  and  then  apply  it  to 
the  granulations  and  to  them  only.  It  produces  no  pain, 
and  may  be  carried  into  the  canal  of  the  cervix  or  even 
further.  In  this  case  it  was  applied  as  far  as  the  os 
internum  two  or  three  times,  at  intervals  of  twelve  or 


44  UTERINE  SURGERY. 

fifteen  days.  A  nutritious  diet,  but  no  medicine  was 
ordered.  In  three  months  the  granulations  and  the 
monorrhagia  were  well,  and  in  three  months  more 
conception  occurred,  and  resulted  in  the  birth  of  a  son, 
after  five  years  of  suffering. 

Menoerhagia  from  Fibrous  Engorgement  of  the 

Cervix. — Mrs. ,  aged  thirty-one,  married  at  twenty 

— two  children,  youngest  eight  years  old — never  well 
since  last  labour — menstruation  formerly  normal,  but 
for  the  last  seven  years  and  a  half  it  recurs  too  early,  and 
lasts  often  ten  days  very  profusely.  Five  or  six  months 
ago  she  had  it  for  three  months  continuously.  She  is 
quite  exsanguious  and  exhausted ;  has  had  some  leucor- 
rhoea  for  the  last  four  or  five  years.  I  was  consulted  as 
much  for  the  removal  of  her  sterility  as  for  the  relief  of 
the  monorrhagia.  She  had  taken  chalybeates,  mineral 
waters,  <fec.,  and  had  been  treated  locally  with  the  nitrate 
of  silver  for  a  very  long  time  without  material  benefit. 
The  neck  of  the  womb  was  the  seat  of  fibrous  engorge- 
ment, with  superficial  granular  erosion.  It  was  consi- 
derably hypertrophied  and  indurated.  The  organ  was 
in  its  normal  position.  The  thickened  indurated  lips  of 
the  OS  uteri  were  in  consequence  of  their  hypertrophy 
in  close  apposition,  the  one  against  the  other,  thus 
mechanically  closing  the  os,  although  it  was  large  enough 
to  admit  a  'No.  8  bougie.  To  the  granulations  on  the 
engorged  fibrous  cervix  I  applied  the  chromic  acid  as 
already  described,  which  healed  the  granular  surface  in 
two  months,  but  did  not  in  the  least  modify  the  haemor- 
rhagic  tendency.  A  sponge  tent  showed  that  there  was 
nothing  abnormal  in  the  cavity  of  the  uterus,  and  I  then 
determined  to  incise  the  os  uteri.  There  were  two 
reasons  for  this : 


OP    MENSTRUATIOK 


45 


1st :  Tlie  bilateral  incision  of  tlie  os  uteri  would 
divide  tlie  indurated  structure  of  the  cervix  through 
its  whole  extent  up  to  the  os  internum,  which  would 
probably  ameliorate  the  engorgement,  and  diminish  the 
hsBmorrhage.  And  2nd :  It  would  separate  the  com- 
pressed lips  of  the  OS  uteri  sufficiently  to  permit  the 
spermatozoa  to  pass  to  the  cavity  of  the  uterus,  thereby 
rendering  conception  possible ;  and  upon  this  taking 
place  I  hoped  for  a  complete  revolution  in  the  nutritive 
functions  of  the  whole  organ,  and  an  ultimate  perfect 
cure. 

Accordingly,  the  operation  of  incision  of  the  os  and 
cervix  bilaterally,  was  performed  on  the  1st  of  October, 
1860.  The  parts  healed  before  the  next  menstrual  flow, 
which  I  was  delighted  to  find  greatly  reduced  in  quan- 
tity ;  indeed,  it  was  almost  natural.     In  three  months 


Pig.  11. 

she  returned  home  with  a  normal  menstruation.  The 
mouth  of  the  womb  presented  a  totally  diiferent  appear- 
ance from  what  it  did  when  she  first  came  under  my 
observation.  For  instance,  when  I  first  saw  her  it  was 
a  simple  little  transverse  slit  (fig.  11),  with  the  opposite 
surfaces  closely  applied  to  each  other;    but  when  she 


46 


UTERIXE   SURGERY. 


left  it  presented  an  entirely  different  appearance :  the 
two  opposite  lips  of  the  os  uteri  slightly  gaj^ing  open  (fig. 
12),  thus  rendering  it  possible  for  the  semen  to  get  to  the 


Fig.  12. 

fundus  uteri.  Mne  months  after  this  lady  left  my  care 
shg  conceived,  and  I  have  since  heard  that  she  was 
safely  delivered  of  a  fine  vigorous  child,  after  an  acquired 
sterility  of  about  nine  years.  The  result  is  most  grati- 
fying, inasmuch  as  a  purely  rational  surgical  treat- 
ment effected  the  cure  of  both  menorrhagia  and  ste- 
rility. 

Of  Menorrhagia  from  Fuis^goid  GRAisruLATioisrs. — 
When  an  old  burn  and  other  chronic  ulcers  refuse  to 
heal,  we  often  find  the  su]3puratiug  surface  to  be  ele- 
vated above  the  level  of  the  sound  skin,  and  we  call  it 
"  proud  flesh,"  "  exuberant  granulation,"  "  fungus,"  or 
"  fungoid  granulation."  It  is  usually  indolent  or  insensible 
to  the  touch,  except,  perhaj)s,just  at  the  cicatrizing  edge 
of  the  cuticle,  and  it  often  bleeds  easily  on  being  touched. 
It  is  a  condition  of  things  very  much  like  this  that 
we  here  designate  "fungoid  granulations,"  as  sometimes 
the  source  of  menorrhagia.     These  may  be  in  the  canal 


OP  MENSTRUATION. 


47 


of  tlie  cervix,  or  in  the  cavity  of  the  uterus,  or  iu  both 
at  the  same  time  ;  but  it  is  more  common  to  find  them 
in  one  or  the  other  alone,  and  perhaps  more  frequently 
in  the  former.  Wherever  located,  they  are  often  the 
source  of  aU  increased  flow,  which  may  be  remedied  by 
local  treatment.  To  diagnose  their  presence,  let  us 
suppose  a  case  of  menorrhagia  for  investigation.  If  the 
touch  proves  that  there  is  no  polypus  or  other  source  of 
it  to  be  found  in  the  vagina,  then  we  must  look  to  the 
cavity  of  the  uterus  for  it.  If  it  be  from  a  granular 
engorged  cervix,  the  speculum  at  once  reveals  the 
cause.  But  if  the  os  and  cervix  be  in  a  healthy  condition, 
then  it  comes  from  some  portion  of  the .  utero-cervical 
canal.  Formerly  we  were  left  in  doubt  about  the 
pathology  of  menorrhagia,  but  we  now  explore  the 
cavity  of  the  unimpregnated  uterus  with  the  greatest 
facility,  and,  no  longer  groping  in  the  dark,  we  are  able 
to  treat  most  cases  of  it  understandingly,  if  not  always 
successfully.  Compressed  sponge  is  a  very  old  surgical 
appliance,  but  in  uterine  therapeutics  it  is  of  compara- 
tively recent  date,  and  I  believe  we  owe  its  generaliza- 
tion here  to  Dr.  Simpson  ;  but  my  own  countrymen. 
Dr.  J.  P.  Batchelder  and  Dr.  W.  C.  Eoberts,  of  New 
York,  have  both  written  very  ably  on  this  subject. 
Sponge  tents  are  now  to  be  had  at  most  druggists  ; 
those  that  we  see  in  the  shops  are  large  clumsy  things, 
thickly  coated  with  wax,  tallow,  or  suet.  They  are  diffi- 
cult to  introduce,  and  often  slip  half  out  of  the  cervix 
into  the  vagina,  there  exciting  an  unnecessary  amount  of 
irritation.  To  be  sure  they  are  well  made,  I  have  them 
manufactured  under  my  own  supervision.  They  are  so 
indispensable  nowadays  that  I  may  be  pardoned  for  a 
little  minutise  on  the  subject.  City  physicians  can  order 
them  fi'om  the  druggist,  but  the  country  practitioner 


48 


UTERINE   SURGERY. 


cannot  always  do  so,  and  this  is  my  apology  for  dwelling 
on  the  subject. 

The  sponge  should  be  of  good  quality,  but  not  too 
soft  and  yielding.  Of  course,  it  should  be  thoroughly 
cleaned ;  but  not  bleached,  for  the  bleaching  process 
deprives  it  of  all  elasticity.  It  should  be  cut  into  slightly 
tapering  conical  pieces,  from  one  to  two  inches  long, 
some  smaller  and  others  much  larger  than  the  thumb. 
A  pointed  wire  or  a  slender  awl  should  be  passed  through 
the  centre  of  the  long  axis  of  the  sponge,  which  should 
then  be  thoroughly  saturated  with  a  thick  mucilage  of 
gum  arable.  A  small  twine  of  cord  is  then  to  be  closely 
wrapped  around  the  sponge  as  it  is  held  stiff  by  the 
wire,  beginning  at  the  smaller  extremity  and  gradually 
winding  on  to  the  larger ;  then  the  wire  may  be  with- 
drawn, and  the  new-made  tent  laid  aside  to  dry.  If  we 
are  in  a  hurry  it  may  be  dried  in  the  sun  or  by  a  fire, 
taking  care  not  to  injure  the  texture  of  the  sponge  by 
too  great  a  heat. 

When  it  is  thoroughly  dry,  the  twine  is  to  be 
unwound,  and  the  little  circular  elevations  made  by  it 
on  the  surface  of  the  tent  are  to  be  rubbed  down  by 
fine  sand-paper.     Without  furthei*  preparation  it  is  then 


Fig.  13. 

ready  for  use.  These  diagrams  represent  the  tents  about 
the  size  and  shape  that  I  usually  make  them.  I  never 
allow  them  to  project  more  than  an  eighth  of  an  inch 
from  the  os  uteri  into  the   vagina.     Being  introduced 


OF  MENSTRUATION. 


49 


without  grease,  except  a  little  suet  just  on  tlie  point, 
they  seldom  slip  out  of  position.  If,  however,  there  is 
a  disposition  on  the  part  of  the  cervix  to  eject  the  tent, 
a  small  pledget  of  lint  or  cotton  laid  on  the  cervix  after 
the  tent  is  introduced,  will  effectually  prevent  this 
accident.  I  have  seen  a  great  deal  of  suffering  produced 
by  sponge  tents,  and  with  all  due  deference  to  the 
dexterity  of  surgeons,  I  must  insist  that  this  is  wholly 
unnecessary.  The  commercial  tents,  as  said  before,  are 
too  large,  and  being  introduced  without  a  speculum 
always  induce  more  or  less  pain.     My  plan  is  this  : — The 


Fig.  14  represents  the  speculum  elevating  the  posterior  Avail  of  the  vagina  ; 
the  tenaculum  fixing  the  uterus  by  being  hooked  into  its  anterior  lip  ; 
and  the  forceps  holding  the  tent,  which  is  introduced  up  to  the  os 
internum. 

patient  being  on  the  left  side,  ray  speculum  is  introduced  ; 
the  OS  uteri  is  pulled  gently  forwards  by  a  delicate 
tenaculum  hooked  into  the  anterior  lip,  which  fixes  the 
uterus,   while  the  tent  held    by   the  forceps    is  passed 

4 


50  UTERINE  SURGERY. 

easily  and  gently  into  the  cervix  to  the  required  deptli, 
without  producing  pain.  I  make  it  a  point  never  to 
introduce  a  tent  that  is  larger  than  the  canal  that  is  to 
receive  it,  and  thus,  if  it  be  gently  done,  it  is  impossible 
to  give  pain  ;  and  why  should  we  ever  inflict  one  single 
unnecessary  pang? 

If  we  have  the  selection  of  the  time  for  the  intro- 
duction of  the  tent,  let  it  be  in  the  morning,  say  by  or 
before  ten  o'clock.  We  should  explain  to  the 
patient, — 

1st :  That  it  may  possibly  produce  a  little  uneasiness, 
which  is  usually  very  bearable. 

2nd  :  That  it  will  certainly  produce  a  dirty,  disagree- 
able, bad  smelling,  watery  dischai'ge,  from  which  the 
person  and  clothing  must  be  protected  by  napkins,  to  be 
changed  as  often  as  necessary.     And — 

3rd  :  That  it  will  be  necessary  to  see  her  in  six  or 
eight  hours,  to  remove  the  tent,  and  probably  to  intro 
duce  another,  if   the  cervix  be  not  already  sufficiently 
dilated  by  the  first  one,  to  permit  the  passage  of  the 
index  finger  freely  into  the  cavity  of  the  uterus. 

If  the  second  tent  be  needed,  it  may  be  allowed  to 
remain  till  the  next  morning.  The  tent  is  valuable  both 
as  a  diagnostic  and  therapeutic  agent,  but  is  to  be  used 
vnth  caution.  If  the  second  tent  fail  to  dilate  the  cervix 
sufficiently,  it  is  safer,  as  a  general  rule,  not  to  persevere 
further  for  the  time,  but  to  wait  a  few  days,  and  then 
resort  to  it  again.  I  am  thus  cautious,  because  I  have 
seen  metritis  follow  its  injudicious  use.  The  tents  of 
commerce  have  a  loop  of  tape,  three  or  four  inches  long, 
fastened  to  the  large  or  outer  extremity,  for  their  easy 
removal. 

I  use  nothing  of  this  sort,  because  I  always  expect 
to  remove  the  tent  myself. 


OF  MENSTRUATION.  5]^ 

Its  removal  is  a  matter  of  some  nicety. 

Place  the  patient  on  the  side  as  for  its  introduction ; 
apply  the  specukim,  and  immediately  we  see  the  sponge 
projecting  from  the  cervix  and  dilated  from  the  size  of 
h  to  that  'of  a  (fig.  15).     It  will  be  saturated  with  a 


Fig.  15. 

foetid,  serous,  or  sero-sanguinolent  discharge,  which 
is  to  be  carefully  wiped  away.  After  this  fix  a  pair 
of  spring  forceps  firmly  on  the  centre  of  the  sponge, 
for  the  purpose  of  removing  it.  Then  let  the  patient 
turn  over  on  her  back,  with  the  forceps  still  fiistened 
to  the  sponge.  Now  23ass  the  left  index  finger  into 
the  vagina  along  the  locked  blades  of  the  forceps, 
till  it  comes  in  contact  with  the  sponge.  The  sponge 
is  not  to  be  suddenly  or  quickly  withdrawn,  but  it 
is  to  be  pulled  gently  first  to  one  side  and  then  to  the 
other,  taking  care  at  the  same  time  to  support  the 
uterus  with  the  index  finger,  which  is  to  be  gentl}^ 
carried  into  the  cervix  by  the  side  of  the  tent,  first 
on  one  side,  then  on  the  other,  to  free  its  meshes  or 
interstices  from  the  cervical  mucous  membrane,  which 
interlocks,  as  it  were,  with  the  substance  of  the  sponge. 
When  the  sponge  has  been  well  loosened  all  I'ound, 
and  is  found  to  slip  down  a  little,  then  we  should 
be  ready  to  thrust  the  finger  up  into  the  cavity  of  the 


52  UTERINE  SURaERT. 

womb,  as  we  pull  it  away.  If  the  finger  does  not 
pass  at  once  and  easily,  it  is  better  not  to  use  much 
force,  but,  as  before  stated,  to  wait  for  another  oppor- 
tunity. The  removal  of  the  sponge  is  always  followed 
by  more  or  less  flow  of  red  blood,  showing  a  laceration 
of  tissue.  The  finger  may  pass  the  os  externum  with 
tolerable  ease,  and  still  not  be  able  to  pass  the  os 
internum,  and  here  it  is  better  to  procrastinate  a  com- 
plete exploration  than  to  use  an  undue  degree  of  force. 
But  if  the  second  joint  of  the  index  passes  the  os 
externum,  the  point  of  the  finger  is  already  in  the  cavity 
of  the  uterus ;  and  then,  while  we  press  the  finger 
onwards  and  upwards  we  should  make  a  counter- 
pressure  with  the  right  hand  just  above  the  pubes, 
grasping  the  fundus  of  the  uterus  through  the  parietes 
of  the  abdomen,  and  forcing  it  down  on  the  end  of  the 
left  index,  as  we  would  push  a  thimble  down  on  it. 
Were  it  not  for  this  outward  counter-pressure,  the 
uterus  would  necessarily  be  pushed  upwards  before  the 
index,  and  we  should  seldom  reach  the  fundus.  There 
are  good  reasons  for  placing  the  patient  on  the  side, 
and  using  the  speculum  for  inspecting  the  sponge  before 
its  removal. 

1st:  It  is  satisfactory  to  know  that  it  has  remained 
precisely  where  it  was  placed. 

2nd :  It  is  well  to  see  what  amount  of  uterine  or 
vaginal  irritation  it  has  produced. 

3rd  :  As  the  sponge  is  saturated  with  a  disagreeable 
discharge,  it  is  well  to  clean  it  and  the  vagina  thoroughly 
before  the  manipulations  necessary  for  a  complete 
uterine  exploration. 

All  this  accomplished,  it  is  a  temptation  to  almost 
any  one  to  pull  the  sponge  away  while  the  patient  lies 
on  the  side,  with  everything  so  nicely  prepared  for  it 


OF  MENSTRUATION,  53 

and  seemingly  inviting  to  it.  But  I  must  specially 
warn  the  surgeon  against  this  temptation.  1st:  Because 
if  the  sponge  be  removed  under  these  circumstances, 
with  the  vagina  widely  open,  the  air  rushes  into  the 
cavity  of  the  uterus,  and  I  am  sure  that  in  my  early 
experience  I  had  the  misfortune  more  than  once  to  see 
metritis  follow  this  accident.  2nd :  Because  the  finsrer 
cannot  be  passed  far  enough  into  the  uterine  cavity 
for  a  thorough  exploration,  unless  the  external  counter- 
pressure  be  made  with  the  other  hand,  which  is  neither 
easy  nor  effectual  in  any  other  position  than  the 
dorsal. 

Having  often  to  recommend  the  use  of  sponge  tents, 
I  shall  necessarily  be  compelled  to  speak  frequently  of 
them  in  these  pages,  and  I  only  regret  that  they  are  so 
disagreeable  as  remedies.  I  never  use  them  if  I  can 
possibly  avoid  it,  and  I  never  apply  them  without 
apologizing  to  my  patient  for  the  very  unpleasant  effects 
they  produce. 

He  who  gives  us  an  efficient,  pleasant,  and  cheap 
substitute  for  sponge  tents,  will  confer  a  great  boon  on 
Surgery.  T  know  of  no  competent  substitute,  or  I  would 
be  too  willing  to  adopt  it.  Having  said  so  much  on  this 
subject,  we  may  now  return  to  "  fungoid  granulations," 
as  a  source  of  menorrhagia. 

To  show  not  only  the  diagnostic  value,  but  the  won- 
derful therapeutic  powers  of  the  tent  in  such  conditions, 
let  me  srive  a  case. 

Mrs.  ,  of  bilious  nervous   temperament,    aged 

thirty-five,  as  a  girl  had  occasional  nervous  attacks, 
and  suffered  from  painful  menstruation.  She  was 
married  at  twenty — was  sterile — had  yellow  fev^er  in 
1858 — and  was  compelled  to  leave  the  South,  and  go  to 
New  York  on  account  of  her  health.     She  had  menor- 


54  UTERINE   SURGERY 

rliagia  from  the  time  of  the  yellow  fever,  in  1853,  till  1 
saw  her,  four  yeai's  afterwards.  She  was  scarcely  ever 
clear  of  a  show  for  more  than  a  week  or  ten  days  out 
of  a  month.  It  was  not  excessive  on  any  one  day,  but 
its  prolonged  continuance  had  exhausted  her  strength 
and  worn  out  her  nervous  system.  She  cauld  not 
undergo  the  least  fatigue — would  fiiint  easily,  even  from 
emotional  causes ;  had  tinnitus  aurium  and  palpitation  ; 
and  blindness  was  such  a  troublesome  symptom,  that 
she  consulted  an  oculist,  who  told  her  that  the  condition 
of  her  eyes  was  wholly  due  to  the  enfeebled  state  of 
her  general  health.  She  had  taken  chalybeates,  tonics, 
ergot,  and  sea-bathing,  without  improvement,  and  at 
last  I  saw  her  in  September,  1857.  I  did  not  dally  a 
moment  with  such  general  constitutional  treatment  as 
would  be  naturally  suggested,  but  at  once  attacked  the 
offending  organ.  The  vagina  was  excessively  tender  to 
the  touch  from  the  ostium  vasjinse  to  the  cervix  uteri. 
This  was  evidently  the  result  of  an  ichorous  sero- 
sanguinolent  discharge  that  was  ever  present  when  the 
haemorrhage,  properly  speaking,  ceased.  The  uterus 
was  retroverted — the  posterior  wall  consequently^- 
hypertrophied ;  the  os  was  very  small ;  the  cervix 
rather  long  and  acuminated, — which  anatomical  pecu- 
liarities explained  her  symptoms  previously  to  mar- 
riage and  her  subsequent  sterility.  From  the  history 
of  the  case,  and  from  the  volume  and  general  condition 
of  the  uterus,  I  expected  to  find  an  intra-uterine 
polypus.  However,  the  sponge  tent  alone  would 
put  all  speculation  at  an  end.  I  should  have  said 
that  the  irritability  of  the  vagina  was  so  great  that 
I  could  only  use  the  smallest  or  virgin-sized  speculum ; 
and  I  was  obliged  to  resort  to  emollient  vaginal  injec- 
tions and  to  glycerine  applications,  for  a  few  days,  to 


ON  MENSTRUATION. 


55 


render  any  speculum  examination  at  all  bearable.  This 
done,  a  very  small  sponge  tent,  not  more  than  an  inch 
long,  was  passed  into  the  cervical  canal.  It  was  worn 
without  inconvenience  for  twenty-four  hours.  It  was 
barely  large  enough,  to  open  the  os  uteri  from  the  size 
of  a*  No.  3  to  that  of  a  No.  8  bous^ie.  But  this  was 
enough  to  permit  me  to  look  into  the  canal,  where  I 
could  plainly  see  the  source  of  the  mischief.     Fig.  16 


Fig.  16. 


would  represent  the  general  outline  and  relative 
position  of  the  uterus  before  the  sponge  tent  was  used  ; 
while  fig.  17  would  show  a  vertical  section  of  the  organ 


Fia.  17. 


after  its  removal,  when  I  could  easily  see  the  vegeta- 
tions on  the  posterior  surface  of  the  cervical  canal,  as 
shown  in  the  diagram.  These  could  have  been  scraped 
away  with  Kecamier's  curette ;  but  I  was  anxious  to 
open  the  canal  more  largely  and  further  up,  into  the 
cavity  of  the  uterus,  with  a  view  of  more  easily  apply- 
ing the  curette,  and  with  the  hope   of  clearing  away 


56  UTERINE    SURGERY. 

whatever  there  might  be  above  the  portion  that  wag 
visible.  Accordingly,  I  introduced  a  tent  two  inches 
long,  and  large  enough  to  fill  completely  the  already 
partially-dilated  cervix.  Of  course  it  passed  over  the 
crop  of  fungoid  granulations,  pressing  them  firmly 
down  into  the  very  surface  from  which  they  sprang. 
I  directed  this  lady  to  call  again  nexL  day.  Her 
residence  was  not  less  than  five  miles  distant  froini  my 
own. 

On  the  succeeding  day,  when  she  was  to  have  come 
to  me,  a  furious  storm  prevented  her  going  out,  and, 
as  she  felt  no  inconvenience,  except  from  the  fetor  of 
the  sponge-tent  watery  discharge,  she  determined  to 
remain  at  home.  But  on  the  next  day  the  weather 
continued  in  the  same  state,  it  being  the  time  of  the 
equinox,  and  I  did  not  see  my  patient  for  seventy- 
two  hours  after  the  introduction  of  the  tent.  I  need 
not  say  how  anxious  I  felt,  for  I  greatly  feared  the 
consequences  of  its  prolonged  retention.  When  I 
came  to  examine  the  vagina,  the  stench  from  the 
sponge  was  almost  unbearable,  and  the  patient 
declared  that  it  had  kept  her  in  a  state  of  nausea  for 
more  than  twenty -four  hours. 

Its  removal — by  no  means  easy — was  followed  by  a 
sudden  profuse  gush  of  bright  red  blood.  I  was  so 
much  alarmed  that  I  did  not  dare  to  resort  to  the 
curette  lest  I  might  add  to  the  irritation  already  set  up 
in  the  parts.  But  of  this  I  satisfied  myself  that  there 
were  no  longer  any  vegetations  in  the  cervix  so  far  as 
could  be  determined  by  the  touch.  I  did  not  permit 
this  lady  to  return  home  for  three  or  four  days,  but 
detained  her  in  New  York  till  I  was  sure  that  she  was 
over  the  dangers,  if  any,  of  the  prolonged  retention 
of  the   tent.      No    medicine    was   given,    and   nothing 


OP  MENSTRUATION.  5'^ 

more  was  done,  but  slie  was  sent  home  to  await  the 
return  of  menstruation. 

This  came  in  due  time,  and  lasted  three  days,  instead 
of  seventeen  or  eighteen  as  before,  being  natural  in 
appearance- and  quantity.  She  was  thus  cured  by  the 
sponge  tent  alone  in  three  days,  and  subsequently 
became  a  mother. 

A  sponge  tent  is  to  us  a  sort  of  necessary  evil.  We 
cannot  do  without  it.  It  is  not  to  be  denied  that, 
while  it  is  powerful  to  do  godll,  it  may  also  be  equally 
powerful  to  do  harm.  From  a  very  large  experience 
of  sponge  tents  in  uterine  disease,  lam  now 'firmly 
convinced  that  we  ought  never  to  apply  them,  under 
any  circumstances,  in  the  consulting-room. 

Whenever  they  are  to  be  used,  the  patient  should 
make  up  her  mind  to  remain  in-doors,  if  not  in  her  bed- 
room, for  some  days,  and  this  even  when  used  only  for 
a  day.  In  hospital  practice  I  do  not  remember  a  single 
mishap  from  them,  simply  because  the  patients  did  not 
go  out  and  expose  themselves  to  the  vicissitudes  of  the 
weather.  Whereas,  after  applying  them  in  the  consult- 
ing-room, I  formerly  had  sevei'al  accidents  from  them 
before  I  could  be  convinced  of  their  noxious  properties. 
However,  with  ordinary  care,  the  tent  is  as  safe  as  any 
remedy  capable  of  doing  good.  And,  since  I  have 
adoj)ted  the  plan  of  treating  private  patients  as  I  do 
hospital  ones,  by  keeping  them  in-doors  during  the  time 
of  sponge  tenting,  I  have  had  no  cause  to  complain  of 
this  agent.  This  course  was  forced  upon  me  by  more 
than  one  such  case  as  the  follovvinoj  : — 

Mrs. ,   aged  thirty-foui',  married  twelve  years, 

the  mother  of  three  children,  the  youngest  five  years  of 
age,  always  had  rather  profuse  menstruation,  but  since 
her  last  labour  it  became  very  profuse,  lasting  ten  oi 


58  UTERINE    SURGERY. 

twelve  days,  and  requiring  tlie  use  of  six  or  eight  nap- 
kins a  da)%  and  sometimes  many  more.  She  also  had 
leucori'hoea.  She  was  of  plethoric  habit,  but  began  at 
last  to  feel  the  effects  of  the  unnatural  loss  of  blood. 
She  had  been  treated  locally  and  constitutionally 
without  improvement. 

The  uterus,  somewhat  anteverted,  was  much  larger 
than  it  should  have  been,  and  the  os  and  cervix  were 
granular,  I,  like  the  physician  who  preceded  me, 
attempted  first  the  cure  of  this  condition.  In  the  course 
of  three  months  my  patient  was  better  of  the  leucorrhoea 
and  granular  erosion,  but  the  menstrual  flow  was  as 
profuse  as  ever.  I  then  determined  to  explore  the 
cavity  of  the  uterus,  expecting  to  find  there  a  fibroid  or 
polypoid  growth,  as  the  body  of  the  organ  was  evidently 
larger  than  it  should  be.  Accordingly,  a  small  tent  was 
introduced,  and  she  was  directed  to  return  the  next 
day.  She  did  so,  having  suffered  no  inconvenience 
from  it.  It  was  removed,  and  a  longer  and  larger  one 
introduced,  and  she  returned  home  in  a  stage,  a  distance 
of  about  four  miles.  This  was  in  January,  and  the 
ground  was  deeply  covered  with  snow.  She  came  to 
see  me  the  next  day,  saying  that  she  was  chilly  the 
night  before.  She  was  then  feverish,  seemed  to  be 
quite  ill,  and  complained  of  pain  in  the  hypogastrium, 
nausea,  &c.  I  removed  the  tent,  but  made  no  effort  at 
uterine  exploration.  She  returned  home,  had  metro- 
peritonitis, was  dangerously  ill  for  many  weeks,  and, 
fortunately,  eventually  recovered,  but  never  again  to 
place  herself  under  my  care.  Now,  if  I  had  visited  this 
lady  at  her  own  residence,  and  applied  the  same  treat- 
ment, I  am  very  sure  that  she  would  not  have  had  the 
serious  illness  that  was  evidently  produced  by  her 
exposure  in  snow  storms,  two  days  in  succession,  while 


OF  MENSTRUATION.  59 

she  rode  each  day,  to  and  fro,  a  distance  of  at  least 
eight  miles,  besides  the  exposure  of  crossing  the  "ferry  to 
Brooklyn  in  a  boat  heated  to,  perhaps  80  degrees,  while 
the  temperature  outside  was  not  more  than  20*^  F. 
During  this  same  winter  ('58)  I  had  two  or  three  other 
cases  similarly  unfortunate.  I  then  resolved  not  to  use 
sponge  tents  again  on  riding  or  walking  patients,  and 
since  then  I  do  not  remember  an  accident  from  them — 
and  this  is  saying  a  great  deal  in  favour  of  their 
innocuousness.  However,  I  use  them  now  with  greater 
caution — for  instance,  when  I  knew  less  about  them  than 
I  do  now,  I  invariably  allowed  a  tent  to  remain  twenty- 
four  hours ;  on  its  removal  a  second  was  usually  intro- 
duced to  be  worn  another  twenty-four  hours;  sometimes 
a  third  was  introduced  for  another  twenty-four  hours  ;  but 
generally,  indeed  almost  always,  I  subjected  the  uterus 
to  this  ti-eatment  for  at  least  forty-eight  hours.  Whereas 
now,  as  I  have  already  described  (page  50),  the  whole 
process  should  not  occupy  more  than  from  twelve  to 
twenty-four  hours  at  any  one  time. 

The  power  of  the  sponge  tent  to  modify  the  uterine 
surfaces  with  which  it  lies  in  contact  is  truly  wonderful. 
It  dilates  the  neck  of  the  womb ;  it  softens  it  by 
pressui-e,  and  by  a  sort  of  serous  depletion  ;  it  reduces 
the  size,  not  only  of  the  neck,  but  of  the  body  of  a 
moderately  hypertrophied  uterus  ;  it  destroys  not  only 
fungoid  granulations,  but  even  large  mucous  polypi ;  and 
in  one  instance  I  saw  a  sponge  tent  destroy  wholly 
a  fibrous  polypus  as  large  as  a  pigeon's  egg. 

This  was  accidental,  but  it  demonstrated  clearly  what 
the  sponge  can  do  by  pressure  and  capillaiy  drainage. 

When  introduced  into  the  cervix,  the  tent  soon 
absorbs  moisture,  and  expands.  It  may  produce  a 
little  pain,  but  it  is  of  no  moment,  and  ceases  ordinarily 


60  UTERINE  SURGERY. 

when  the  dirty  serous  or  sero-sanguinolent  discharge 
l)egins.  The  meshes  of  the  sponge  and  the  surface  Avith 
whicii  they  are  in  contact  become,  after  some  hours, 
intimately  incorporated.  The  sponge  forces  itself  into 
the  very  structure  of  the  cervix,  and  the  mucous  mem- 
brane of  the  cervix  shoots  out  into  the  interstices  of  the 
sponge,  so  that  it  is  somewhat  difficult  to  separate  the 
two  if  the  tent  has  been  worn  for  any  length  of  time. 
On  its  removal,  there  is  necessarily  a  laceration  of  the 
tissue  incorporated  with  it.  This  lacerated  surface 
generally  heals  smoothly  over  in  a  few  days  after, 
obliterating  every  trace  of  the  original  indolent  fungoid 
growth  that  gave  rise  to  the  menorrhagia.  Thus,  it 
seems  to  perform  the  duties  of  M.  Recamier's  curette  in 
a  most  efficient  manner,  but  I  do  not  pretend  that  it 
would  always  supersede  it. 

The  curette  is  simply  the  adjuvant  of  the  tent,  and 
always  to  be  preceded  by  it.  But  there  are  cases  where 
their  relationship  is  changed,  the  sponge  becoming  the 
adjuvant  of  the  curette,  and  this  is  when  the  fungoid 
granulations  are  at  the  fundus  uteri.  Then  the  sponge 
is  to  dilate  the  cervix  for  the  more  easy  application  of 
the  curette. 

In  cases  of  menorrhagia  that  resisted  all  other  treat- 
ment, Kecamier  passed  his  curette  into  the  uterine 
cavit}^,  and  raked  it  out  as  thoroughly  as  possible. 
This  was  before  the  days  of  sponge  tents.  But  now  we 
first  dilate  the  cervix,  pass  the  finger  into  the  cavity, 
ascertain  precisely  the  seat  of  the  fungoid  growth,  pass 
the  curette  by  the  side  of  the  finger,  and  thus  operate 
more  understand  ingly. 

Fig.  18  represents  the  curette  that  I  use;  the 
handle  is  malleable  and  may  be  bent  laterally,  or 
backwards,  or  forwards,  in  the  direction  of  the  dotted 


OF  MENSTRUATION. 


61 


lines,  a.,  h.     Thus  it  can  be  used  with 
equal  facility  on  any  portion  of    the  » 
uterine  cavity.     I  hav^e  lately  had    it   \ 
made    with  a    ball  and  socket    joint,     \ 
in    the    middle  of  the  shaft,   but    the 
simple   instrument,  as  here   delineated 
answers  quite  as  well. 

To  show  the  power  of  the  sponge 
to  destroy  mucous  polypi,  I  will  select 
one,  and  only  one,  of  many  cases  that 
I  mio;ht  biin^  forward. 

In  November,  1862,  I  was  con- 
sulted by  a  lady  in  Paris,  who  was 
seemingly  a  perfect  specimen  of  health, 
but  she  was  sterile.  Mensti'uation 
had  always  been  rather  profuse,  last- 
ing eight  or  nine  days. 

The  uterus  was  retro  verted,  but 
what  would  seem  contradictory,  it  was 
also  anteilected.  Suffice  it  for  the 
present  to  say,  that  the  cervical  canal 
was    enlarged    by   a  bilatei'al   incision.  "^^  ^g 

The  operation  was  performed    in   De- 
cember, 1862,  with  the  assistance  of  Sir  Joseph  Olliffe. 

The  parts  as  usual  healed  before  the  next  men- 
struation, which,  however,  was  not  much  influenced 
by  the  operation,  for  it  went  its  usual  course  of  eight 
or  nine  days.  After  it  was  over  I  was  examining  the 
condition  of  the  cervical  canal,  and  to  my  sui-prise,  I 
saw  the  end  of  a  mucous  poly|)Us  or  enlarged  nabothian 
gland  lying  high  up  in  the  canal,  as  sliown  at  a^  in 
fig.  19.  I  passed  a  sponge  tent  in  the  morning  along 
the  canal  of  the  cei-vix,  above  and  lieyond  the  seat  of 
the  polypus.     In  the  afternoon  I  removed  the  tent  and 


02  UTERINE   SURGERY. 

introduced  a  longer  and  larger  one,  and  allowed  it  to 
remain  till  the  next  morning.  On  its  removal  there 
was  no  trace  of  the  polypus  to  be  found.     Menstruation 


Pig.  19. 

immediately  became  normal,  and  has  continued  so  ever 
since. 

This  power  of  the  sponge  tent  to  destroy  polypoid 
growths  was  accidentally  discovered  at  the  Woman's 
Hospital  in  this  way.  In  1856  a  young  unmarried 
woman  entered  the  hospital  with  a  menorrhagia  that 
had  bled  her  quite  into  a  dropsical  condition.  The 
flow  was  almost  continuous,  but  attended  with  no 
great  degree  of  pain ;  she  was  perfectly  anaemic  from 
loss  of  blood ;  had  general  anasarca,  and  was  of  a  waxy 
hue.  We  did  not  suspect  the  true  character  of  her 
disease ;  and  Dr.  Emmet  and  myself  agreed  to  give  her 
a  nutritious  diet,  with  chalybeates ;  and  so  she  went  on 
bleeding  for  several  days  longer,  and  a  sponge  tent 
was  then  introduced.  The  uterus  did  not  seem  to  the 
touch  to  be  much  enlarged,  and  it  was  only  two  inches 
and  a  half  to  the  fundus.  The  cervix  was  small,  and 
the  OS  was  correspondingly  so.  When  the  tent  was 
removed  there  presented  one  of  the  most  perfect 
specimens   of   fibroid   polypi   that   I   ever   saw.      The 


OP  MENSTRUATION. 


63 


diagram    (fig.    20)    shows    its    attacliment    and    rela- 
tions. 

It  had  given  me  much  trouble,  and  was  a  nice  case 
for  operation,  which  might  have  been  performed  at  the 


Fig.  20. 


moment,  but  I  was  anxiou=^  to  show  it  to  the  Con- 
sulting Board  of  the  Woman's  Hospital,  and  concluded 
to  put  off  its  removal  till  the  next  day,  which  was  the 
day  for  their  regular  meeting.  Accordingly  I  intro- 
duced a  large  sponge  tent,  expecting  to  remove  it  on 
the  following  day,  and  complete  the  operation  in  the 
presence  of  the  Board.  Singularly,  they  did  not  meet, 
and  the  poor  patient  with  the  sponge  tent  was  com- 
pletely forgotten.  I  expected  Dr.  Emmet  to  remove 
the  tent,  and  he  thought  I  had  done  it ;  and  the  nurse, 
who,  by  the  by,  never  forgot  a  patient,  supposed  we 
had  left  it  intentionally.  However,  about  a  week 
afterwards,  the  nurse  begged  to  call  ray  attention 
to  the  young  woman  Avith  the  spono^e  tent,  saying  she 
thought  "'it  must  be  rotten  by  this  time,  as  the  other 


64  UTERINE    SURGERY. 

patients  in  the  same  ward  with  her  conhl  not  stand 
the  smell  of  it  any  longer."  My  mortification  at  such 
neglect,  added  to  the  dread  of  seiious  results  to  the 
poor  patient,  may  well  be  imagined.  However,  she 
was  soon  on  the  operating  table,  complaining  of 
nothing  but  the  intolerable  fetor  of  the  sero-san- 
guinolent  discharge,  which  had  been  going  on  con- 
stantly for  a  whole  week.  The  sponge  and  the  tissue 
of  the  cervix  seemed  to  be  thoroughly  amalgamated, 
and  it  was  necessary  to  push  the  point  of  the  finger 
up  between  the  two,  and  gi-adually  separate  them  all 
round  before  making  traction  on  the  sponge  with  the 
forceps.  I  never  performed  a  more  unpleasant  opera- 
tion than  the  removal  of  the  sponge;  the  stench  was 
such  as  to  make  one  of  the  nurses  vomit.  When  the 
tent  Avas  introduced  a  week  before,  the  tumour  was 
accurately  measured,  its  volume,  density,  and  attach- 
ment all  definitely  settled,  and  easily  so.  It  was  a  dense, 
firm,  fibrous  polypus,  about  the  shape  of  the  diagram  on 
page  63 — a  little  larger,  and  having  attachment  to  the 
fundus  as  there  represented.  My  surprise  may  be 
imagined  when,  on  introducing  the  finger  into  the 
cavity  of  the  uterus,  after  the  removal  of  the  tent,  there 
was  not  a  vestio;e  of  the  tumour  to  be  found.  The 
pressure  and  drainage  by  the  sponge  had  eradicated  it 
entirely.  The  patient  speedily  recovered,  and  was  soon 
restored  to  a  vigorous  state  of  health.  Notwithstand- 
ing the  happy  result  of  this  accident,  and  the  valuable 
principle  thereby  established,  I  would  not  recommend 
it  as  a  rule  of  practice  in  fibroid  polypi.  For  the  dan- 
ger of  metritis  by  the  prolonged  contact  of  such  an 
irritant,  and  the  still  greater  danger  of  pyaemia  from 
the  disintegration  of  tissue,  would  render  it  too  hazard- 
ous.     However,   the   tent   may   always    be   trusted   /^o 


OP  MENSTRUATION. 


65 


destroy  fungoid  growths  and  small  raucous,  or  nabo- 
thian  polypi,  when  they  cannot  be  otherwise  removed. 
Dr.  Emmet,  surgeon  to  the  Woman's  Hospital,  whose 
experience  with  the  sponge  tent  is  very  large,  has  the 
greatest  confidence  in  their  safety  as  well  us  efficiency. 
I  have  seen  him  repeat  them  day  after  day,  and  I  have 
often  heard  him  say  that  he  has  succeeded  in  doing 
more  for  general  hypertrophy  of  the  uterus  by  this 
means  in  a  week  than  could  be  accomplished  by  any 
and  all  others  in  two  or  three  months. 

I  have  said  a  good  deal  about  the  disgusting  dis- 
charge produced  by  the  sponge  tent.  While  at  Baden- 
Baden  in  the  summer  of  1863,  I  had  occasion  to  use  a 
tent,  and  apologized  to  my  patient  for  its  bad  effects. 
In  her  case  I  had  been  previously  using  glycerine  dress- 
ings to  the  womb.  As  the  tent  showed  a  little  dispo- 
sition to-  slip  down,  I  applied  a  pledget  of  cotton, 
saturated  with  Price's  glycerine,  over  the  neck  of  the 
uterus,  simply  because  it  was  convenient  to  do  so. 
When  I  went  to  remove  the  sponge  in  the  afternoon, 
my  patient  told  me  that  the  discharge  had  no  bad 
odour,  and,  on  examination,  I  found  the  pledget  of 
cotton  and  tent,  after  removal,  perfectly  devoid  of  any 
fetor.  I  have  now  often  used  this  as  a  disinfectant 
of  the  sponge,  and  find  it  infallible  in  its  results.  The 
only  objection  to  it  is  that  it  sometimes  prevents  the 
sponge  from  expanding  to  its  fullest  extent. 

I  have  used  tents  of  the  Laminaria  digitata,  and 
think  well  of  them,  but  they  can  never  wholly  replace 
the  sponge  tent.  There  is  much  trouble  in  retaining 
them  properly  in  place.  It  is  often  necessary  to  prop 
them  up  with  a  tampon,  and  even  then  they  slip  out. 
Besides  this,  they  require  a  much  longer  time  to  dilate 
the  cervix.     However,  they  are  a  valuable  addition  to 

5 


66 


UTERINE    SURGERY. 


our  surgical  resources,  and  for  tliem  we  are  greatly  in- 
debted to  the  late  Dr.  Sloan,*  of  Ayr,  Scotland. 

Dr.  Greenhalgh  has  improved  tLe  Sea  Tangle  tent 
very  much,  and  it  happened  in  this  way.  He  had 
some  trouble  in  getting  a  pair  of  forceps  made  specially 
for  their  introduction,  and  the  idea  occurred  to  him  to 
perforate  the  lower  end  of  the  tent  for  the 
insertion  of  a  stylet,  which  answered  a 
good  purpose.  But  he  soon  discovered 
that  the  perforated  part  dilated  more 
easily  and  to  a  greater  degree  than  the 
rest  of  it.  He  then  had  the  perforation 
made  throus^h  the  whole  leno-th  of  the 
tent,  when  he  found  that  it  acted  more 
rapidly  and  more  efficiently  than  before. 
The  tents  of  commei'ce  up  to  this  time  were 
tied  round  with  a  thread  at  the  'lower  end 
to  facilitate  their  removal.  This  interfered 
with  the  dilatation,  by  preventing  the  ex- 
pansion of  the  tubular  perforation  below. 
He  then  had  the  thread  fastened  to  one 
side  of  the  tent  as  shown  in  the  diagram 
(fig.  21).  I  agree  entirely  with  Dr.  Green- 
halgh that  the  tent  should  not,  as  a  rule, 
exceed  two  inches  in  length. 

Prepared  after  Dr.  Greenhalgh's  plan, 
it  is  much  softer  when  removed  from  the 
uterus  than  the  solid  tent,  and  the  perfora- 
tion is  found  of  be  dilated  in  proportion  to 
the  expansion  of  the  solid  part,  thus  serving  as  a  drain 
to  facilitate  the  escape  of  any  secretions  from  the  cavity 


Fig.  21. 


*  O^asgow  Medical  Journal^  October,  1862. 


OF  MENSTRUATION.  Q'J 

of  the  uterus.  JSTotwitlistanding  all  this,  I  regret  to  say 
they  do  not  fulfil  all  the  indications  of  the  sponge  tent, 
and  cannot  wholly  replace  it. 

Of  MENOPamAGiA  from  Polypus. — Having  spohen 
of  menorrhagia  as  a  sequence  of  granular  erosion,  of 
cervical  engorgement,  and  of  fungoid  granulations,  we 
now  come  to  consider  it  as  a  concomitant  of  polypus. 
Accoucheurs  and  pathologists  have  described  polypi 
as  soft,  hard,  mucous,  glandular,  cellular,  cystic, 
fibrinous,  fibro-cellular,  fibro-cystic,  and  fibrous.  These 
several  divisions  are  anatomically  and  pathologically 
correct  ;  but  as  I  am  taking  only  a  surgical  view  of  the 
subject,  I  prefer  to  classify  them  topographically,  that 
is,  not  according  to  their  own  structural  elements,  but 
simply  according  to  their  point  of  origin,  which,  b}^  the 
bye,  is  the  simplest  method  of  arrangement.  Thus,  I 
would  say  that  uterine  polypi  are  naturally  divided  into 
three  classes  : — 


1st.  Those  growing  from  or  about  the  os  tincse. 
2nd.  Those  srrowino^  in  the  canal  of  the  cervix. 
3rd.  Those  growing  in  the  cavity  of  the  uterus. 


The  first  may  be  fibro-cellular  or  mucous. 

The  second  are  almost  always  mucous. 

The  third  are  almost  always  fibrous. 

I  propose  to  give  clinical  illustrations  of  these  sub- 
divisions. 

In  the  first  class  they  may  be  large  or  small.  If  of 
the  fibro-cellular  variety,  they  may  attain  an  enormous 
size.  I  have  seen  them  almost  as  large  as  the  foetal 
head  at  term.  If  of  the  mucous  variety,  they  seldom 
grow  larger  than  an  English  walnut,  and  are  usually 
somewhat  flattened  by  pressure  between  the  cervix  and 


68  UTERINE  SURGERY. 

the  opposite  wall  of  the  vagina.  To  the  sight  these 
seem  to  be  only  a  congeries  of  fibro-cellular  tissue  and 
blood-vessels.  Polypi  growing  from  the  os  tincae  are 
generally  attached  to  one  lip  of  it,  I  am  not  able  to 
say  upon  which  one  they  are  most  frequently  found. 
They  often  prevent  conce^^tion,  but  not  always,  for 
our  medical  literature  contains  numerous  examples  of 
labour  complicated  with,  or  obstructed  by,  very  large 
polypi,  which  could  hardly  have  grown  during  the 
period  of  gestation. 

Their  removal  is  easy  enough.  They  may  be  cut 
off  with  scissors,  or  removed  by  the  ecraseur.  I 
know    that  fatal  hamorrhasre  has  followed  the  use  of 

o 

scissors,  but  it  was  before  the  discovery  of  the  styptic 
properties  of  the  perchloride  of  iron  by  Pravaz.  This 
was  indeed  a  boon  to  surgery,  and  Deleau*  has 
rendered  a  great  service  in  vulgarizing  its  use. 

But,  unfortunately,  it  is  a  remedy  of  uncertain 
properties.  It  often  contains  free  acid,  and  then  it 
irritates  the  mucous  surface  of  the  vagina.  So  uncer- 
tain is  this  preparation  in  New  York,  that  the 
profession  there  have  almost  entirely  abandoned  its 
use,  substituting  for  it  the  solution  of  the  persulphate 
of  iron  (as  made  by  Dr.  Squibb,  of  New  York),  which 
seems  to  be  quite  as  efficient  and  is  not  so  liable  to 
the  same  objections.  In  Paris  I  could  not  get  the 
persulphate  of  iron,  and  I  was  obliged  to  return  to  the 
use  of  the  perchloride  as  a  styptic.  Mr.  Swaun, 
chemist.  Rue  Castiglione,  procured  for  me  specimens 
of  the  perchloride  which  j^urported  to  be  neutral,  but 


*  "  Traite  Pratique  sur  les  Applications  du  PercWorure  de  Per  ea 
Medecine."  Par  M.  T.  Deleau,  Docteur  en  Medecine,  &c.  Paris :  Adrian 
Delabaye.     1860. 


OF    MENSTRUATION. 


69 


they  produced  very  deleterious  effects  on  the  vaginal 
epithelium,  and  at  last  he  got  some  of  Deleau's,  and  its 
effects  were  as  desired,  viz.  styptic  and  unirritating. 

We  will  suppose  a  polypus  growing  from  the 
posterior  lip  of  the  os  tincse,  with  a  pedicle  half  an 
inch,  more  or  less,  in  diameter  (fig.  22).      If  it   is  to 


¥m.  22. 


be  removed  by  scissors,  first  prepare  the  styptic  by 
mixing  one  part  of  the  solution  of  the  perchloride  of 
iron,  with  three  or  four  of  distilled  water ;  then 
saturate  pledgets  of  lint  in  it,  or,  what  is  better, 
take  some  fine  cotton  wool,  wet  it  thoroughly  in 
plain  water,  squeeze  all  the  water  out,  and  then  wet 
it  in  the  mixture,  and  squeeze  it  nearly  dry. 

When  all  is  ready,  place  the  patient  in  the  semi- 
prone  position,  apply  the  speculum,  lay  hold  of  the 
tumour  with  forceps,  or  a  vulsellum,  draw  it  gently 
forwards,    and    cut  it  off  at  one    stroke   with  suitable 


70  UTERINE    SURGERY. 

scissors.  Sponge  the  cut  surface  a  moment,  and  quickly 
apply  the  lint  or  cotton  previously  prepared,  and 
press  it  firmly  in  place  with  a  sponge  probang  (fig. 
23).  The  firm  pressure  of  one  or  two  sponge  probangs 
on  the  styptic  lint  oi-  cotton  almost  instantly  checks  the 
bleeding.  Wait  a  little  to  be  sure  of  this,  and  then 
put  a  tampon  of  dry  cotton  over  all,  merely  to  secure 
the  dressing  proper  in  situ.  The  patient  is  put  to  bed, 
the  recumbent  position  is  enjoined  for  a  day  or 
two,  and  the  bladder  m^  or  may  not  be  emptied 
by  the  catheter. 

On  the  next  day  the  dry  cotton  is  to  be 
removed,  taking  care  not  to  disturb  the  iron 
dressing  in  contact  with  the  cut  surface.  This 
adheres  closely  to  it,  and  is  not,  as  a  general  rule, 
to  be  removed  till  it  is  loosened  and  thrown  off 
by  the  suppurating  process,  which  takes  two, 
three,  or  even  four  days. 

But,  when  the  dry  cotton  is  removed  on  the 
day  after  the  operation,  its  place  is  to  be  supplied 
by  a  bit  of  cotton  saturated  with  Price's  glyce- 
rine, which  is  to  be  I'enewed  daily,  till  the  cut 
surface  be  healed.  For  this  purpose  take  some 
fine  cotton,  as  much  as  can  be  easily  held  in  the 
hollow  of  the  hand,  immei'se  it  in  tepid  water, 
and  squeeze  it  gently  under  the  water  till  it 
becomes  perfectly  wet ;  then  press  all  the  water 
out  of  it,  and  saturate  it  with  Price's  glycerine. 
To  do  this,  lay  the  moistened  cotton  in  the  palm  of  the 
left  hand,  spread  it  out  circularly  for  an  inch  and  a  half 
in  diameter,  more  or  less  as  may  be  needed,  scooping  it 
out  in  the  centre — then  drop  half  a  teaspoonful  of 
glycerine  on  it  thus  held,  and  rub  it  into  the  cotton  witli 
the  point  of  the  finger,  then  pour  on  a  little  more  gly- 


FiG.  2^ 


OF  MENSTRUATION. 


n 


cerine,  and  rub  it  in,  and  so  continue  till  the 
cotton  becomes  saturated.  When  finished,  the 
cotton  should  feel  soft  and  pulpy,  should  be  about  an 
inch  and  a  half  in  diameter,  and  about  half  an  inch 
thick. 

This  dressing  is  an  expensive  one,  for  it  will  hold 
from  one  to  three  drachms  of  glycerine ;  but  I  do  not 
think  there  is  any  substitute  for  it,  and  its  effects  are 
such  that  I  consider  it  cheap  in  the  end. 

This  glycerole  cotton  is  thus  applied  daily  till  the 
fii'st  dressing  is  removed,  and  then  it  may  be  conti- 
nued for  a  few  days  longer,  till  the  whole  surface  be 
healed. 

Glycerine  is  now  fixed  in  professional  estimation  as  a 
most  valuable  addendum  to  the  domain  of  surgery ;  and 
to  the  philosophic  and  practical  mind  of  Demarquay* 
are  we  indebted  for  a  complete  treatise  on  tlie  subject, 
setting  forth  its  properties  and  qualities.  Its  use  in 
uterine  surgery  occurred  to  me  some  seven  or  eight  years 
ago,  in  this  way  : — To  a  case  of  granular  engorgement  I 
wished  to  apply  some  caustic  or  other;  but,  whatever  it 
was,  I  could  not  at  once  find  it.  Being  very  much  hur- 
ried, I  looked  around  for  some  substitute.  And  it 
occurred  to  me  to  apply  a  bit  of  cotton  wet  with  glyce- 
rine, merely  to  protect  the  os  uteri  from  contact  with  the 
opposite  surface  of  the  vagina,  which  was  also  quite 
granulai-.  I  fully  intended  to  use  the  caustic  on  the  next 
day.  But,  when  my  patient  returned,  she  saluted  me 
with,  "  Well !  doctor,  what  eflect  did  you  intend  the 
treatment  of  yesterday  to  produce?"  Seeing  that  there 
was  evidentlv  something  out  of  the  way,  I  was  quite  at 


*  "  De  la  Glycerine,"  <&c.     Par  M.  Demarquaj.     Paris.    1863. 


72  UTERINE    SURGERY. 

a  loss  for  a  satisfactory  reply  ;  and  slie  continued,  "  You 
ouglit  to  have  told  me  all  about  it,  for,  when  I  got  home, 
ray  linen  was  so  wet  that  I  had  to  change  it,  and  the  water 
streamed  from  me  all  night  in  such  a  way  that  I  have 
had  to  wear  napkins  to  protect  myself"  This  was  all 
news  to  me,  and,  on  examination,  I  found  the  pledget  of 
cotton  still  wet,  lying  just  as  it  was  placed  on  the  cervix 
uteri,  which,  together  with  the  vagina,  had  a  clean, 
healthy,  and  greatly  improved  appearance,  compared 
with  what  it  had  the  day  before.  I  applied  another 
similar  dressing,  to  see  if  it  would  produce  the  same 
effect.  It  did,  and  these  dressings  were  repeated  till  the 
case  was  entirely  cured  :  since  which  time  I  have  used 
glycerine  in  this  way  in  all  my  surgical  operations  on 
the  neck  of  the  womb,  and  in  other  cases  of  organic 
lesion. 

The  effect  of  glycerine  thus  used  is  very  remarkable. 
It  has  great  affinity  for  water.  A  bit  of  cotton  saturated 
with  glycerine,  and  exposed  to  the  air,  will  retain  mois- 
ture for  weeks.  When  applied  to  the  neck  of  the  womb 
as  above  directed,  it  seems  to  set  up  a  capillary  drainage 
by  osmosis,  producing  a  copious  watery  discharge,  deplet- 
ing the  tissues  with  which  it  lies  in  contact,  and  giving 
them  a  dry,  clean,  and  healthy  appearance.  When  such 
a  dressing  is  applied  to  a  pyogenic  surface  on  the  cervix 
uteri,  for  a  few  hours,  and  then  removed,  the  cut  or  sore 
will  be  as  clear  of  pus  as  if  it  were  just  washed  and 
wiped  dry. 

Much  has  been  written  on  the  diagnosis  of  polypous 
tumours.  I  do  not  intend  to  open  the  subject  here, 
but  I  would  only  say  that  the  Gordian  knot  is  easily 
cut,  if  my  method  of  exploration  be  adopted  ;  for, 
with  the  patient  on  the  side  (or  knees,  if  necessary), 
with  ray   speculum  everything   is  brought  so   plainly 


OF  MENSTRUATIOIT. 


73 


into  view  that  tliere  is  no  possibility  of  making  a  mis- 
take. 

Dr.  Graily  Hewitt  and  Dr.  Greenhalgh  have  related 
cases  where  physicians  were  in  doubt,  and  had  even  mis- 
taken a  common  polypus  for  carcinoma.  I  have  seen 
several  cases  of  mucous  polypi  slightly  jirotruding  from 
the  cervix  that  had  been  treated  for  granular  erosion  by 
repeated  applications  of  nitrate  of  silver;  and  a  few 
years  ago  I  saw  a  woman,  forty-eight  years  of  age, 
greatly  reduced  by  prolonged  haemorrhages,  who  pre- 
sented almost  exactly  the  cachectic  physiognomy  of 
carcinoma.     She  had  none  of  the  lancinating  pains  of 


cancer,  but  when  the  finger  was  passed  into  the  vagina, 
it  found  a  knobby  hard  growth  occupying  the  place  of 
the  cervix,  and  the  os  could  not  be  felt. 

When  the  ordinary  speculum  was  used,  this  growtli 


T4 


UTERINE    SURGERY. 


Fig.  25. 


filled  up  its  area,  and  all  was  in  doubt.     But,  by  the  use 

of  my  speculum,  wliicTi  left 
the  whole  vagina  freely  open 
to    inspection,    we   found   a 
polypus  of  mushroom  shape 
fitting  almost  like  a  cap  over 
the    cervix    uteri    (fig.    24). 
The   pedicle  was  short,  and 
the  tumour  fitted  so  well  the  projecting  portion  of  the 
cervix,  that  it  was  scarcely  movable.     The  removal  of 
the  tumour  with  scissors  exhibited  an 
OS  tinea)  perfectly  free  from  all  appear- 
ance of  maliijnant  disease.    A  not  un- 
frequent    form    of    polypus    is    repre- 
sented by  fig.   25.     This  was  removed 
from  a  lady  who  supposed  it  was  the 
wom]:»   coming   out,  because  it  protru- 
ded  from  the    mouth    of  the   vagina. 
When  I  told  her  it  was  a  fibro-cellular 
polypus,  she  was  greatly  alarmed,  be- 
cause she  had  lost  one  of  her  servants 
by  an  operation  of  some  sort  for  poly- 
pus. 

All  classifications  are  more  or  less 
arbitrary.  This  polypus  might  l^y  some 
be  classed  in  my  second  subdivision  ; 
but  as  it  grew  distinctly  from  the  edge 
of  the  OS  tincse,  although  some  of  its 
fibres  took  root  in  the  cervical  mucous 
membrane,  I  have  put  it  in  the  first 
class. 

AYe  often  find  small  polypi  in  the 
canal  of  the  cervix.      They  vary  from 


OF  MENSTRUATION. 


75 


the  size  of  a  grain  of  wheat  to  that  of  a  small  bean, 
and  are  called  nabothian  polypi.  (See  fig.  19,  page 
C2.) 

They  may  be  ^^eiy  effectually  destroyed  by  the  me- 
chanical pressure  of  a  sj^onge  tent  worn  for  twenty-four 
hours,  or  they  may  be  pulled  off  by  forceps,  or  cut  off 
with  scissors  ;  I  prefer  the  latter.  We  often  fail  in  the 
extraction  of  small  mucous  or  cystic  polypi,  for  the 
want  of  a  suitable  instrument. 

Dr.  McClintock  uses  a  fenestrated  forceps  for  these, 
which  answers  admira1:»ly.  A  vulsellum  is  not  suitable 
here,  because  their  tissue  is  so  delicate  that  it  is  apt  to 
tear  out.  Fig.  26  represents  Dr.  McClinto.-k's  polypus 
forceps.  They  compress  the  pedicle,  while  the  little 
polypus  lies  unhurt  in  the  fenestral  opening.  But  for 
larger  ones,  such  as  fig.  25,  Charriere  has  made  for  me 


Fig.  27. 


forceps  of  this  sort  (fig.  27),  with  which  we  seize  tlie 
pedicle  of  the  polyp,  when  we  wish  either  to  tear  it 
away  or  cut  it  off  with  scissors. 

But  suppose,  for  some  reason,  we  wish  to  remove  a 
polypus  by  torsion.  To  render  this  process  perfectly 
safe,  it  is  necessary  that  the  pedicle  be  long  and  slender, 


^JQ  UTERINE    SURGERY. 

and  that  the  tumour  be  easily  rotated.  Tills  process  has 
been  applied  to  the  small  nabothian  polypi  and  also  to 
intra-uterine  fibrous  polypi  witli  slight  attachments. 
Laying  hold  of  the  polypus  with  a  fenestrated  forceps,  if 
of  the  first  variety ;  with  a  vulsellum,  if  of  the  second ; 
we  rotate  gently  from  left  to  right,  and  so  continue  till 
all  resistance  ceases,  when  we  remove  the  severed 
growth.  I  am  no  advocate  for  this  plan,  unless  under 
very  exceptional  circumstances. 

There  are  but  few  polypi  that  cannot  be  safely 
removed  with  scissors,  yet  we  may  have  reasons  for 
not  wishing  to  resort  to  them.  The  patient  may  be  so 
exhausted  by  repeated  and  prolonged  haemorrhages,  that 
we  cannot  afford  to  risk  the  sudden  loss  of  an  additional 
small  quantity  of  blood;  or  from  some  theoretical  grounds 
we  may  prefer  not  to  cut.  For  instance,  in  Paris, 
surgeons  often  refuse  to  perform  the  simplest  cutting 
operation  when  there  is  much  erysipelas  about,  asserting 
that  a  clean  cut  is  more  apt  to  produce  erysipelas,  and  even 
pysemia,  than  the  lacerated  wound  of  the  ecraseur.  Be 
this  as  it  may,  let  us  suppose  that  we  have  to  deal  with 
a  polypus  too  formidable  for  scissors  or  for  torsion.  Our 
only  resource  then  is  the  ecraseur, — and  a  very  sure  and 
safe  one  is  it :  sure  in  its  action  and  safe  in  its  conse- 
quences. Formerly  a  ligature  was  passed  round  the 
pedicle  of  such  tumours,  and  tightened  from  time  to 
time  till  the  mass  sloughed  away;  but  that  day  has  gone 
by,  never  to  return. 

The  removal  of  a  polypus  by  ligation  is  really  a 
dangerous  operation,  resulting  not  unfrequently  in 
pysemia  and  death,  which  seldom  indeed  happens  when 
the  ecraseur  is  used. 

We  owe  this  admirable  instrument-  to  the  inventive 
genius  of  Chassaignac. 


OF  MENSTRUATION.  7^ 

It  has  been  used  in  almost  every  imaginable  way,  and 
often  most  inappropriately ;  for  instance,  for  fistula  in 
ano,  for  the  removal  of  simple  steatomatous  tumours,  for 
excision  of  the  mamma,  for  lithotomy,  and  even  for 
amputation  of  the  thigh.  But  the  time  is  coming,  indeed 
is  even  here,  when  the  true  surgeon  will  raise  it  to  the 
dignified  position  that  it  merits,  by  confining  it  to  such 
operations  as  are  peculiarly  its  own.  For  the  ablation 
of  diseased  structure  in  erectile  tissue  it  cannot  be  over- 
estimated. In  Chassaignac's  ward  in  the  Larriboisiere 
Hospital  I  have  seen  cases  where  malignant  disease  of 
the  tongue  called  for  the  removal  of  that  organ,  whicb 
was  done  safely  by  this  admirable  instrument,  and  the 
patients  remained  well  for  a  long  time  afterwards.  In 
the  same  wards  I  have  seen  more  than  one  case  in  which 
M.  Chassaignac  had  removed  the  anus,  and  a  large 
portion  of  the  rectum,  for  cancei'ous  disease,  an  operation 
that  would  have  been  utterly  impossible  by  any  other 
means,  and  one  of  these  patients  had  been  well  for  more 
than  a  year. 

These  are,  fortunately,  rare  cases,  but  they  prove  the 
value,  efficiency,  and  safety,  of  the  ecraseur  under  the 
worst  possible  conditions.  But  it  is  for  the  removal  of 
haemorrhoids  and  uterine  polypi  that  this  instrument 
is  to  find  its  most  common  and  appropriate  field  of 
usefulness. 

Many  modifications  have  been  made  of  Chassaignac's 
chain  ecraseur.  M.  Maisonneuve  uses  a  stiff  but  malle- 
able iron  wire,  to  be  pulled  through  the  tissue.  Dr. 
Braxton  Hicks  makes  a  cord  of  several  fine  threads  of 
wire ;  while  others  fix  one  end  of  the  chain  (Charri^re 
and  Tieman).  I  have  tried  all  these,  and  have  no  hesi- 
tation in  saying  that  none  of  them  are  in  practice  equal 
to  Chassaignac's  original  instrument.     It  generally  cuts 


Y3  TJTEUINE  SURGERY. 

througli  neatly,  without  drawing  out  long  shreds  ol 
tissue,  leaving  us  uncertain  when  the  tumour  is  entirely 
severed,  if  it  be  hidden  from  view,  as  it  must  be  some- 
times. Every  little  click  of  Chassaignac's  instrument 
measures  for  us  most  accurately  the  distance  over  which 
the  chain  passes,  warning  us  to  rest.  The  resistance  we 
encounter  in  tightening  it  shows  us  the  density  of  tissue, 
and  is  the  index  to  move  slower  or  faster.  Whereas, 
every  turn  of  a  screw,  whether  a  quarter,  half,  or  whole 
revolution,  leaves  us  in  doubt  whether  it  is  too  much  or 
too  little — while  it  is  a  power  unmeasured  and  unappre- 
ciated by  the  sense  of  feeling.  This  is  strongly  proven 
by  the  fact  that  I  have  never  broken  one  of  Chassaig- 
nac's instruments,  while  I  have  broken  two  worked  by  a 
screw.  The  same  thing  has  occurred  in  the  dexterous 
hands  of  Dr  Graily  Hewitt  and  of  Dr.  McClintock. 

McClintock,  in  speaking  of  the  ecraseur  for  uterine 
polypi,  says,  "  I  have  generally  felt  it  necessary  to  bring 
the  bulk  of  the  tumour  beyond  the  external  genital 
orifice ;  and  this  necessity  it  is  that  limits  its  range  of 
applicability."*  The  difficulty  of  placing  the  chain 
around  the  pedicle  of  the  tumour  while  in  the  vagina, 
and  the  still  greater  one  of  applying  it  within  the  uterus, 
has  been  heretofore  the  great  barrier  to  its  universal 
adoption.  But  I  hope  this  difficulty  is  now  overcome. 
I  do  not  think  the  polypus  should  ever  be  drawn  outside 
for  ecrasement,  or  that  there  should  be  any  undue  trac- 
tion made  on  the  uterus  while  the  ecraseur  is  being 
worked.  My  plan  is  this.  The  patient  in  proper  posi- 
tion, the  speculum  (fig.  5)  is  introduced,  and  we  have  a 
complete  view  of   everything   in   the  vagina.      If  the 


*  "  Clinical  Memoirs,"  &c.,  p.  171. 


OF    MENSTRUATION. 


79 


tunic ar  is  in  the  vagina,  there 
will  not  be  the  least  difficulty 
in  applying  the  chain  of  the 
6craseur ;  but,  to  do  this  with 
facility,  it  is  necessary  to  prevent 
the  chain  from  folding  on  itself,  as 
we  attempt  to  carry  its  loop 
over  and  beyond  the  tumour. 
This  was  to  me  a  source  of  an- 
noyance for  a  long  time,  but  at 
last  I  have  succeeded  in  giving 
the  chain  a  rigid  fixity  that 
makes  it  very  easy  to  do  this. 

Where  the  polypus  has  de- 
scended into  the  vagina,  Maison- 
neuve's  wire,  or  Dr.  Braxton 
Hicks'  cord  of  wire,  answers  very 
well ;  but  where  it  is  intra-uterine, 
with  a  contracted  cervix,  we 
ordinarily  fail  in  their  application, 
just  as  we  do  with  the  chain  of 
Chassaisrnac. 

I  have  added  to  Chassaignac's 
instrument  a  porte-chaine,  which 
may  b«i  described  as  a  pair  of 
dilating  forceps  with  spring 
blades,  which  render  the  chain 
stiff,  so  that  it  may  be  passed 
straight  into  the  vagina,  or  into 
t  he  cavity  of  the  uterus,  as  easily 
as  we  would  a  sound  or  a  sponge 
j^i'obang.  After  which  the  chain 
is  expanded  by  the  blades  of  this 
portecnanie. 


80 


UTERINE   SURGERY. 


Fig.  28  represeats  the  ecraseur  with  the  porta- 
chaine  ready  for  use.  It  is  carried  into  the  vagina  or 
into  the  cavity  of  the  womb  thus  arranged;  the  thumh- 
piece,  5j  is  then  pushed  forward  and  fastened  at  the  de- 


dS 


^■d 


1 


Fig.  29. 


Fig.  30. 


sired  point  by  the  notched  rack,  which  is  seen  passinj^ 
through  the  shaft  of  the  instrument  ;  this  moveraeiU 
dilates  the  spring  blades   of  the   porte-chaine,  and   ex- 


OF  MENSTRUATION.  g;|^ 

pands  tlie  chain  to  the  required  extent.  When  tlie 
chain  is  made  to  encircle  the  pedicle  of  the 
tumour,  the  porte-chaine  is  drawn  up  into  the  shaft  of 
the  instrument  simply  by  elevating  the  thumb-piece,  h^ 
and  pulling  it  back  in  a  straight  line  for  three  or  four 
inches,  while  the  instrument  is  puslied  forward  along 
the  cliain  just  as  if  there  had  been  no  porte-chaine 
present.  The  porte-chaine  is  not  wholly  removed 
from  the  ecraseur  ;  it  lies  in  its  place  in  the  shaft  while 
the  operation  is  being  finished.* 

Fig.  29  represents  the  porte-chaine  detached  from 
the  ecraseur,  for  the  purpose  of  showing  its  mecha- 
nism. When  the  thumb-piece  h  is  pushed  forward,  e 
being  a  fixed  point  as  shown  in  figs.  28  and  30,  the 
joints  dd  must  of  necessity  be  forced  apart,  and  this 
it  is  that  dilates  the  blades  c  <?,  which,  holding  the 
chain  securely  in  its  grooves  f  f-,  g  g^  carries  it  out 
to  tlie  required  degree,  as  represented  in  fig.  30. 

Fig.  30  shows  the  angles  or  joints,  d  d^  projecting 
through  slots  in  the  sides  of  the  shaft.  The  only 
thing  necessary  to  insure  the  perfect  working  of  the 
apparatus  is  to  see  that  the  pivot  e,  as  shown  in  all 
three  of  the  cuts,  is  quite  at  the  extreme  end  of  the 
groove,  at  the  top  of  the  instrument.  If  by  chance 
it  should  not  be,  then  the  joints,  d  d^  will  not  have 
room  to  expand  and  project  out  of  the  sides  of  the 
instrument  through  the  slots  made  for  this  purpose. 

The  chain  is  worked  by  a  hidden  rack  in  the  handle, 
g  (fig.  28).     When  the  button,  a,  is  pushed  towards  d^ 


*  The  mechanism  of  this  instrument  has  been  greatly  simpHfied  since  I 
presented  it  to  the  Obstetrical  Society  iu  December,  1864,  and  published  an 
account  of  it  in  the  Lancet.  For  this  improvement  I  am  indebted  to  Mr.  J. 
Mayer,  instrument-maker,  51  Great  Portland  Street. 

6 


82 


UTERINE   SURGERY. 


the  teeth  of  the  rack  are  caught  by  the  notches  in 
the  side's  of  the  two  long  shafts  that  run  from  /  through 
the  whole  length  of  the  instrument ;  when  it  is  moved 
towards  c?,  then  its  teeth  are  elevated  out  of  these  notches, 
and  the  chain  and  porte-chaine  can  be  freely  pushed  up 
and  down  the  shaft  like  the  piston-rod  of  a  syringe. 
This  part  of  its  mechanism  is  exactly  the  same  as  that  of 
Chassaignac's  instrument,  except  that  it  is  simplified, 
hidden  from  view,  and  not  in  the  way  of  the  operator. 

Let  me  illustrate  the  principle  of  its  application  by 
a  clinical  observation.  In  February,  1863,  Dr.  Morpain, 
of  Paris,  invited  me  to  operate  on  a  patient  of  his,  who 
had  a  polypus  as  large  as  a  goose's  egg  projecting  partly 
from  the  cavity  of  the  uterus. 

Fig.  31  represents  its  position,  relations,  and  attach- 
ment. A  moment's  glance  shows  the  difficulty  of  pass- 
ing   a    chain    around   the  pedicle  of    a    tumour   thus 


Fig.  31. 


situated.  The  patient,  on  a  table,  was  placed  in  the  left 
lateral  semi-prone  position,  and,  when  the  speculum  was 
introduced,  it  elevated  the  perineum  and  posterior  wall 
of  the  vagina,  and  brought  completely  into  view  the 
tumour,  as  represented  in  the  engraving. 

There  is  great  temptation  under  such  circumstances 


OF  MENSTRUATION.  33 

to  seize  the  projecting  portion  of  the  polypus  with  a 
strong  vulselium  or  tenaculum,  and  pull  it  towards  the 
OS  externum.  But  this  is  not  the  best  thing  to  do, 
because  it  will  close  up  the  mouth  of  the  vagina  and 
obstruct  both  sight  and  manipulation  ;  for  the  mouth 
of  the  vagina,  even  in  favourable  cases,  would  hardly  be 
forced  open  more  than  an  inch  and  a  half  from  the 
urethra  back  to  the  perineum,  and  we  need  all  this  space 
for  operating. 

Here  a  small  tenaculum  was  hooked  into  the  tumour 
at  «,  and  by  it  the  polypus  was  pushed  gently  down- 
wards and  forwards  against  the  anterior  wall  of  the 
vagina.  It  was  held  firmly,  while  the  stiffened  chain  of 
the  ecraseur  was  passed  along  the  upper  or  posterior 
surface  of  the  tumour  fi'om  a  up  to  the  fundus  uteri  at  c. 
This  done,  the  tenaculum  was  removed,  and  the  chain  of 
the  ecraseur  opened  out  in  the  cavity  of  the  uterus  to  a 
sufficient  extent  to  allow  the  tumour  to  pass  through  it. 
This  was  effected  by  hooking  the  tenaculum  at  h^  and 
raising  the  end  of  the  tumour  up  towards  the  posterior 
wall  of  the  vagina,  at  the  same  time  that  the  ecraseur 
was  pressed  in  the  opposite  direction.  This  movement 
placed  the  middle  portion  of  the  chain  parallel  w^ith  the 
anterior  face  of  the  tumour,  while  its  loop,  or  distal 
portion,  still  remained  stationary  at  c.  It  was  thus  made 
to  embrace  the  pedicle,  and  it  only  remained  to  pull  the 
porte-chaine  back  at  the  same  moment  that  the  shaft  of 
the  instrument  was  pushed  down  on  the  chain,  which 
was  tightened  closely  around  the  pedicle.  The  operation 
was  then  finished  as  easily  as  if  the  tumour  had  been 
wholly  outside  the  body,  and  that,  too,  without  the 
least  strain  or  traction  on  the  uterus  or  surrounding 
organs. 

This  operation  was  done  with  the  assistance  of  Dr 


84 


UTERINE   SURGERY. 


Morpain,  Sir  Joseph  Olliffe,  and  Dr.  W.  E.  Johnston. 
Since  then  (February,  1863)  I  have  had  every  reason 
to  feel  satisfied  with  the  porte-chaine,  whether  the 
polypus  was  in  the  uterus  or  simply  in  the  vagina. 
When  I  was  in  Dublin,  in  August,  1861,  Dr. 
M'Clintock  asked  me  to  see  a  young  woman  in 
the  Itotunda  Hospital  who  had  an  intra-uterine 
polypus.  It  was  about  the  size  of  a  pullet's  egg, 
and  entirely  within  the  cavity  of  the  uterus  (fig.  32). 
She  was  a  virgin ;  the  vagina  was  of  course  small,  and 


Fig.  32. 


the  mouth  of  it  quite  contracted  ;  thus  any  manipulation 
was  diificult.  We  succeeded,  however,  in  getting  a  rope 
of  wire  on  the  tumour  two  or  three  times,  and  succeeded 
as  often  in  breaking  it ;  and  thus,  for  tlie  want  of  proper 
machinery,  we  were  compelled  to  let  the  case  alone  for 
the  time  beinij:.  If  we  had  then  had  the  Chassaiirnac 
instrument  with  the  porte-chaine,  there  would  have  been 
comparatively  little  difficulty  in  removing  the  tumour 
at  once. 

Intra-uterine  polypi  grow  from  the  fundus,  or  from 
the  anterior  or  posterior  walls  of  the  uteius,  l:)ut  more 
frequently  from  the  anterior.  I  do  not  reraem])er  to 
have  removed  any  with  simply  a  lateral  attachment.  It 
has  so  happened  that  I  have  seen  more  polypi  attached 
to  the  anterior  than  to  the  posterior  face  of  the  uterine 


OF  MENSTRUATION. 


85 


cavity.  If  observation  sliould  establish  this  as  a  rule,  it 
will  be  very  fortunate  in  a  surgical  point  of  vie;v  ;  for  it 
is  much  easier  to  pass  the  chain  of  the  ecraseur  around 
the  pedicle  of  a  j^olypus  attached  anteriorly  than  pos- 
teriorly, if 'it  be  entirely  intra-uterine.  An  example  of 
each  variety  may  serve  for  clinical  illustration.  Dr. 
Morpain's  case  already  related  is  a  fair  specimen  of  one 
variety ;  but,  as  showing  the  improved  methods  of 
modern  surgery,  I  may  be  permitted  to  allude  briefly  to 
another  similar  case. 

In  February,  1S60,  a  lady  from  one  of  the  eastern 
States  consulted  me  on  account  of  her  sterility.  She 
was  thirty-two  years  old ;  had  been  married  ten  years  ; 
enjoyed  very  good  general  health,  and  had  leucorrhoea 
and  some  pain  with  menstruation,  which  was  not  profuse. 
The  uterus  was  in  ]3roper  position,  but  felt  larger  than 
natural.  I  introduced  a  sponge  tent  to  ascertain  the 
cause  of  this  hypertrophic  state.  On  its  removal,  the 
finger  passed  into  the  cavity  of  the  uterus  detected  a 


Fig.  33. 


fibrous  polypus  of  the  size  of  a  partridge's  egg,  attached 
anteriorly,  as  represented  in  fig.  33.  Another  spongtj 
tent  of  larger  size  was  introduced,  and  on  its  removal 


S(3  UTERINE  SURGERY. 

six  or  eiglit  hours  afterwards,  I  succeeded  in  p;issiug  the 
chain  of  the  ecraseur  around  the  pedicle,  when  it  was 
easily  and  quickly  severed.  This  case  strongly  illus- 
trates the  present  improved  methods  of  exploration  ;  for 
here  Ave  could  not  have  determined  the  cause  of  the 
uterine  enlargement  but  by  passing  the  linger  into  the 
cavity  of  the  organ  after  dilatation  of  the  cervix. 
Indeed,  before  the  use  of  sponge  tents  we  could  not  by 
any  possibihty  have  diagnosed  such  a  case  as  this.  But 
now  we  determine  Avith  the  minutest  accuracy,  not  only 
the  presence,  but  the  size,  position,  relations,  and 
attachment  of  all  such  tumours.  Before  the  use  of 
sponge  tents,  if  Ave  suspected  from  rational  symptoms 
an  intra-uterine  polypus,  AA^e  could  only  wait  from  month 
to  month — sometimes  from  year  to  year — for  it  to  groAV 
and  to  force  its  way  into  the  vagina,  before  we  could 
interfere  surgically  for  its  removal.  But  now  Ave  no 
longer  doubt  and  procrastinate ;  we  no  longer  let  our 
patients  bleed  till  they  become  bloodless  and  dropsical ; 
but  we  ferret  out  at  once  the  source  of  mischief,  and 
remove  it  from  its  once  secure  hiding-place.  This  is  a 
great  advance  in  surgery ;  and  no  man  of  tAventy  or 
thirty  yeai's'  experience  can  look  back  on  the  days  of 
ergot  and  Gooch's  canula,  and  contrast  them  with  the 
present  time  of  sponge  tents  and  the  ecraseur,  without 
a  thrill  of  delight  at  the  progress  of  our  noble  calling. 

Having  now  given  clinical  illustrations  of  polypi 
growing  from  the  os,  in  the  canal  of  the  cervix,  and  in 
the  cavity  of  the  uterus  attached  to  the  anterior  wall, 
I  will  continue  the  series  by  examples  of  polypi  groAving 
from  the  fundus  and  the  posterior  Avail.  As  said  before, 
I  do  not  remember  any  with  a  simple  latei*al  attach- 
ment. 

A.  H.,  aged  twenty-six,  gave  birth  to  her  only  child 


OF   MENSTRUATION. 


87 


when  she  was  but  fourteen.  Had  two  or  three  miscar- 
riages since,  at  about  the  third  month.  Had  menor- 
rbagia  for  many  years,  very  profuse,  painful,  and 
coagulated,  lasting  usually  ten  or  twelve  days.  Had 
forcing  paips  during  the  whole  time  of  the  flow,  and, 
singularly  enougli,  they  w^ere  always  worse  in  the  fore- 
noon. This  patient  was  sent  to  the  Woman's  Hospital 
by  Professor  J.  C.  Nott,  of  Mobile.  The  womb  was  in 
its  normal  position,  and  evidently  enlarged.  The  os 
admitted  the  end  of  the  index  linger  to  the  depth  of  the 
nail.  She  had  just  menstruated,  and  there  was  a  very 
profuse  muco-purulent  discharge  from  the  cavity  of  the 
uterus.  For  years  her  suffering  bad  been  a  mystery.  A 
sponge  tent  unravelled  it  in  a  few  hours.  She  had  a 
fibroid  polypus  attached  to  the  fundus  by  a  short,  thick 
pedicle  (fig.  34).     It  was  in)])ossible  to  place  the  chain 


Fig.  34 


of  the  ecraseur  around  it,  through  a  comparatively  con- 
tracted cervical  canal.  This  was  before  we  had  learned 
the  use  of  wire  as  a  substitute  for  the  chain.  With  a 
Gooch's  eanula  I  put  a  strong  fishing-line   around  the 


8§  UTERINE  SURGERY. 

pedicle,  and  severed  it  witli  tbe  screw  ecraseur.  It  was 
difficult  to  get  a  cord  strong  enough  to  cut  through  its 
fibrous  tissue.  It  snapped  a  large  catgut  guitar-string^ 
and  then  a  silli  cord.  With  Chassaignac's  ecraseur, 
armed  with  a  porte-chaine,  there  would  have  been  no 
trouble. 

So  far  I  have  spolven  only  of  successful  operations ; 
but  there  is  such  a  thing  as  failure,  and  even  death, 
in  consequence.  Fortunately,  these  are  rare.  I  have 
removed  a  great  many  intra-uterine  poljq^i,  and  all  with- 
out accident,  except  in  two  instances,  which  were  followed 
by  pyaemia.  One  of  these  recovered,  the  other  died. 
This  latter  was  an  example  of  polypus  with  attachment 
to  the  posterior  wall  by  a  thick,  short  pedicle.  It  was 
the  case  of  a  lady  about  sixty  years  old.  I  was  invited 
to  see  her  by  Professor  Metcalfe,  of  Nevv^  York.  She 
was  the  mother  of  a  large  family  of  grown-up  children  ; 
had  ceased  to  menstruate  some  ten  or  twelve  years 
before,  but  for  the  last  three  or  four  years  had  suffered 
alarming  haemorrhages,  which  greatly  prostrated  her. 
The  uterus  was  felt  to  be  enlarged,  but  the  os  was  not 
larger  than  the  point  of  a  common  probe.  A  small 
sponge  tent  was  introduced,  and  on  the  next  a  larger 
one.  This  dilated  the  canal  of  the  cervix  sufficiently, 
but  the  OS  barely  admitted  the  end  of  the  finger,  and 
felt  as  inelastic  as  if  bound  by  wire.  Of  course,  no 
fui'ther  effi^rt  could  then  be  made.  Eight  or  ten  days 
after  this  we  succeeded  in  dilating  the  cervix,  so  as  to 
explore  most  satisfactorily  the  cavity  of  the  uterus, 
when  we  found  a  hard  fibi-ous  polypus,  with  a  broad, 
thick  pedicle,  attacked  to  the  posterior  wall,  close  to  the 
fundus  (fig.  35).  This  was  in  May,  1862.  I  failed  to 
put  the  chain  around  the  pedicle.  Two  weeks  afterwards 
another  series  of  sponge  tents  was  followed  by  another 


OF   MENSTRUATION. 


89 


failure.  The  tumour  was  unfortunately  lacerated  a  good 
deal  by  the  vulsellum,  which  was  used  to  draw  it  down- 
wards and  to  fix  it  while  efforts  were  made  to  pass 
the  chain  around  it.     Two    or  three  days    after  this  a 


'"^^ 


chill  ushered  in  an  irritative  fever,  which  unhappily 
terminated  fatally.  Here  a  valuable  life  was  lost  because 
our  art  did  not  furnish  the  proper  sui-gical  appliances 
for  relief.  With  the  ecraseur,  as  now  supplied  with  the 
porte-chaine,  there  is  every  reason  to  believe  that  we 
would  have  succeeded  in  our  first  efforts. 

In  cases  like  this,  occurring  in  advanced  life,  we  often 
find  it  difiicult  to  dilate  the  os  extei-num.  The  tent 
may  expand  the  canal  of  the  cervix  to  the  size  of  the 
finger,  while  the  os  tincse  may  not  become  larger  than  a 
No.  10  bougie.  Under  these  circumstances,  if  we 
attempt  to  force  the  finger  into  the  cervix,  the  contracted 
OS  feels  rigid  and  resisting  as  if  bound  round  ])y  a  fine 
wire.  And  here,  instead  of  repeating  the  tents,  it  is 
safer  and  better  to  divide  with  the  knife  the  sharp,  well' 


90  UTERINE   SURGERY. 

defined  edges  of  the  contracted  os,  whicli  will  then 
permit  the  finger  to  pass  at  once  to  the 
cavity  of  the  womb.  This  diagram  (fig.  36) 
represents  tlie  relative  expansion  of  a  tent 
worn  for  six  or  eight  hours,  where  the  canal 
of  the  cervix  was  dilated,  while  the  os  tincae 
remained  comparatively  contracted  : — <2,  the  i 
cervical  portion ;  />,  the  part  constricted  by 
the  OS ;  <?,  the  vaginal  portion. 

I  have  now  completed  the  series  that  I 
proposed  to  give  as  types  of  this  disease. 

Time  was  when  women  died  of  polypi 
without  any  eflPort  being  made  for  their 
relief  This  is  not  so  now.  No  delicate  operation  is 
easier ;  none  more  successful.  Life  is  sometimes  lost 
because  we  think  the  patient  so  near  death  that  any 
interference  would  only  accelerate  the  fatal  issue.  This 
is  a  great  mistake.  To  save  life  where  death  is  immi- 
nent, we  are  justified  in  assuming  great  responsibilities 
and  even  in  taking  great  risks.  I  fear  that  we  some- 
times hesitate  to  do  our  duty  by  asking  ourselves  the 
question,  ''  How  will  it  affect  me  if  I  fail  ? "  It  has  been 
said  of  a  great  American  lithotomist  that  he  often 
refused  his  skill  to  bad  cases  because  they  might  spoil 
the  statistics  of  his  unparalleled  success. 

In  December,  1S61,  Mr.  Preterre,  an  eminent  Ame- 
rican dentist  in  Paris,  asked  me  to  see  Madame  R-.,  in 
consultation  with  her  physician.  She  had  menorrhagia 
for  many  years,  and  was  extremely  prostrated  by  it,  and 
by  a  profuse  muco-purulent  vaginal  discharge,  which 
had  been  present  for  six  or  eight  months  whenever  the 
haemorrhage  ceased.  She  had  been  seen  by  many  of 
the  most  eminent  surgeons  in  Pai'is,  but  no  one  suggested 
anything  for  her  relief     I  found  the  uterus  retro  verted 


OP  MENSTRUATION. 


91 


and  greatly  enlarged,  the  fundus  extending  quite  to  tlie 
hollow  of  the  sacrum,  and  .seemingly  filling  up  the 
whole  of  this  region.  A  glance  showed  at  once  that  it 
could  be  but  one  of  two  things — a  polypus  or  a  fibroid 
tumour.  The  os  tincse  admitted  the  end. of  the  index 
finger.  I  was  anxious  to  determine  the  nature  of  the 
case,  and  made  gentle  but  persistent  pressure  with  the 
finger  for  some  moments  through  the  cervix.  It  gradu- 
ally yielded  to  the  force,  and  the  finger,  gliding  to  the 
cavity  of  the  uterus,  detected  an  enormous  fibrous  poly- 
pus, which  could  not  pass  outwards  because  of  the 
retroflexion.  I  was  obliged  to  be  in  London  the  next 
morning,  but  promised  to  return  to  Paris  in  a  week,  for 
no  other  purpose  than  to  apply  a  sponge  tent  and 
remove  the  polypus  for  Madame  R.  Five  or  six  days 
after  my  departure  they  telegraphed  to  me  that  she  was 
much  worse  ;  that  a  consultation  of  physicians  had 
decided  that  it  was  now  too  late  to  attempt  any  opera- 
tion, and  therefore  that  it  was  unnecessary  for  me  to  return 
to  Paris.  Fortunately,  the  telegram  was  not  received, 
and  I  returned  to  Paris  to  find  my  patient  in  a  state  of 
complete  exhaustion.  She  had  a  profuse,  dirty,  ofi:ensive, 
sero-sanfi:uinoleut  dischar<2:e  from  the  vaijina,  whicli 
poisoned  the  whole  atmosphere  of  her  apartment.  Her 
pulse  was  small  and  rapid ;  she  was  quite  anaemic,  and 
presented  all  the  appearances  of  blood-poisoning.  On 
passing  my  finger  into  the  vagina,  I  found  it  entirely 
filled  by  an  immense  fibroid  polypus  in  a  state  of  decom- 
position. She  was  evidently  dying  from  the  absorption 
of  the  detritus  of  this  fetid  mass.  At  my  first  visit,  a 
week  before,  this  tumour  was  wholly  intra-uterine,  but 
now  it  filled  the  vagina.  I  infer  that  its  escape  from 
the  cavity  of  the  uterus  was  due  to  powerful  contrac- 
tions provoked  by  the  forcible  introduction  of  the  finger 


92  UTERINE  SURGERY. 

for  exploration,  for  she  grew  worse  from  tlie  moment  of 
my  visit.  She  had  forcing  pains,  as  of  labour,  for  a 
while,  and  afterwards  passed  into  the  low  condition  in 
which  I  found  her.  Its  pedicle  (as  is  most  usual)  grew 
from  the  anterior  wall.  What  was  to  be  done?  There 
was  assuredly  but  one  course  to  pursue.  If  we  allowed 
this  great  mass  to  remain  there  and  slough  away,  death 
was  absolutely  certain.  Its  speedy  removal  gave  the 
only  hope  of  rescue.  Her  physicians  consented  to  its 
ecrasement,  which  occupied  ten  or  twelve  minutes. 
Vaginal  washes,  wine,  and  a  generous  diet  soon 
completed  tbe  cure.  If  I  had  received  the  telegram, 
she  would  certainly  have  died,  and  I  should  have  been 
censured  by  her  friends  for  hastening  the  fatal  issue, 
inasmuch  as  my  previous  visit  was  the  inauguration  of 
a  new  phase  of  hei-  sufferings.  If  I  had  been  afraid  to 
operate  because  she  was  almost  in  a  moribund  state,  she 
would  unquestionably  have  been  lost.  For  the  success- 
ful after-treatment  of  this  case  I  am  indebted  to  Dr. 
Morpain. 

I  have  related  this  case  perhaps  too  minutely,  but 
it  is  to  encourage  the  young  man  never  to  falter  in  the 
clear  path  of  duty  to  his  patient,  and  to  show  that 
extreme  exhaustion  is  no  barrier  to  the  mere  operation ; 
for,  when  effected  by  the  ecraseur,  there  is  no  danger 
of  haemoi'rhage,  and  very  little  of  any  other  character. 

I  have  no  idea  how  many  polypi  Dr.  Emniett  and 
myself  have  removed  at  the  Woman's  Hospital  and  in 
private  practice,  and  the  case  of  Professor  Metcalfe 
above  related  is  the  only  fatal  one.  This  great  success 
is  certainly  due  to  the  fact  that  we  always  used  the 
ecraseur  or  scissors.  It  would  seem  that  by  these  the 
operation  is  almost  always  safe,  while  by  deligation  it  is 
fraught  with  great  danger. 


OP  MENSTRUATION.  93 

Dr.  Graily  Hewitt  is  wholly  opposed  to  deligation ; 
so  are  many  other  recent  writers.  Dr.  M'Clintock  has 
written  most  clearly  and  ably  on  this  question.*  He 
reports  ten  operations  by  ligature,  of  which  three  wer^ 
fatal,  and  'twenty-four  by  knife,  scissors,  or  ecraseur. 
without  a  single  death.  He  says,  moreover  (p.  183), 
that  "  a  very  high  rate  of  mortality  followed  the  use  of 
the  ligature  in  the  cases  reported  V)y  Dr.  K.  Lee ;  for, 
of  fifty-nine  instances  where  the  ligature  was  applied, 
nine  of  the  women  died,  and  two  of  these  deaths 
occurred  before  the  removal  of  the  tumour  was  effected. 
.  .  .  Dr.  Lee  gives  thirty -five  other  cases  where  polypi 
were  reinoved  by  torsion  or  excision,  and  amongst  these 
there  is  no  death." 

After  this,  it  seems  to  me  that  it  would  be  not  only 
hazardous,  but  absolutely  culpable  in  us  ever  to  resort 
to  deligation  when  there  is  any  chance  of  immediate 
ablation  either  by  excision  or  ecrasement. 

Before  closing  this  subject,  I  may  mention  that 
Dr.  J.  H.  Aveling,  of  Sheffield,  has  added  a  valuable 
instrument  to  our  suro:ical  resources  for  the  removal  of 
polypi  on  the  principle  of  ecrasement.  It  is  represented 
in  fig.  37.  The  thumb-piece  a  is  connected  with  the 
projection  h  by  a  rod,  which  slides  along  a  groove 
in  the  shaft,  which  is  driven  by  means  of  the  screw  at 
the  handle  of  the  instrument.  When  the  extremity  g 
is  placed  around  the  pedicle,  the  part  h  is  made  to 
sever  it  by  being  forced  through  till  it  is  entirely  lost 
in  the  fenestral  opening  in  the  curved  extremity.  Dr. 
Aveling  calls  this  instrument  the  Polyptiite.  It  is 
described  in  the  Obstetric  Transactions,  vol.  4. 


♦  "  Oliniord  Memoirs,"  pp.  183-186. 


94 


UTERINE  SURGERY. 


^ 


Of  Me^storrhagia  from  Fibrous  Tu 
HOURS. — The  uterus  is  particularly  prone 
to  the  development  of  fibroid  tumours. 
They  occur  at  all  ages  after  puberty.  They 
are  seen  in  young  girls  under  twenty,  and 
in  the  octogenarian,  and  may  vary  from  the 
size  of  a  pea  to  that  of  the  gravid  uterus  at 
full  term.  They  are  in  themselves  inno- 
cuous, except  mechanically,  as  when  they 
exert  an  undue  pressure  upon  the  blad- 
der, rectum,  or  pehac  nerves  and  veins, 
or  when  they  produce  haemorrhages.  They 
frequently  prevent  conception,  but  not 
necessarily  and  invariably  so.  They  are 
classed  according  to  the  manner  of  their 
attachment  to  the  walls  of  the  uterus — as 
extra-uterine,  intra-uterine,  andintra-mural. 
Extra-uterine  fibroids  grow  from  any 
portion  of  the  external  surface  of  the 
uterus,  and  may  be  pedunculated;  or 
they  may  be  sessile,  with  a  broad  immova- 
ble attachment  to  its  outer  muscular  tis- 
sue. 
The  intra-uterine  project  into  the  cavity  of  the 
womb,  and,  like  the  first,  may  be  pedunculated  or 
sessile;  and  here  we  make  a  distinction  in  practice  but 
not  in  theory,  calling  the  one  a  fibroid  polypus  because 
it  is  pedunculated,  the  other  a  fibroid  tumour  because 
it  is  sessile,  having  a  broad  attachment  usually  to  one 
wall  of  the  womb ;  the  one  being  remedied  with  com- 
parative ease,  the  other  with  great  difficulty. 

The  intra-mural  are  so  called  because  they  are  em 
bedded  in  the  walls  of  the  uterus,  being  interlaced  and 
overlapped  in  all  directions  by  its  muscular  fibres. 


Fia  37. 


OF  MENSTRUATION. 


95 


Fibroid  tumours  interfere  mechanically  witli  con- 
ception ;  for  instance,  they  may  antevert  or  retrovert 
the  uterus,  and  throw  the  os  out  of  its  normal  relation 
with  the  axis  of  the  vagina.  They  may  elevate  the 
whole  organ  high  up  in  the  pelvis,  so  that  the  semen 
may  never  come  in  contact  with  the  os  even  momen- 
tarily. They  may  compress  the  canal  so  as  to  produce 
a  mechanical  obstruction  to  the  passage  of  the  semen, 
or  they  may  produce  haemorrhages  which  would  be 
fatal  to  the  life  of  the  germ  even  if  vivified.  I  have, 
however,  occasionally  seen  pregnancies  where  there  had 
been  for  years  large  fibroid  tumours. 

Of  225  women  who  had  once  borne  children  and  then 
became  sterile,  38  had  fibroid  tumours  of  various  sizes, 
and  variously  seated — or  one  in  Q^.  Two  were  fibroids 
of  the  posterior  lip  of  the  os  tincae;  the  remainder, 
of  the  body  of  the  uterus.     Of  these, 


Six  were  pedunculated 


Twenty  were  sessile 


Nine  were  intra-mural 


2  on  the  anterior  wall. 

2  on  the  posterior  wall. 

1  on  the  left  side. 

1  on  the  right  side. 

2  on  the  fundus. 

5  on  the  anterior  wall — one  very 

large. 
8  on  the  posterior  wall. 
5  on  the  right  side — none  on  the 

left. 

1  in  the  fundus. 
7  in  the  anterior  wall. 
1    in    the    posterior    wall — very 
large. 


One    intra-uteriue — very    large  and    growing    from    ihe    posterior 
walL 

Of    250    married    women    who    had    never   borne 
children,  the  cause  of  sterility  was  found  to  be  compli- 


96 


UTERINE  SURGERY. 


catecl  witli  the  presence  of  fibroid  tumours  in  57,  being 
at  the  rate  of  about  one  in  4to.     Of  these, 


Five  were  pedunculated 


Twenty-one  were  sessile 


Thirty-one  were  intra-mural      .     ■{ 


2  on  the  anterior  wall. 
2  on  the  posterior  wall. 

1  on  the  fundus. 

8  on  the  anterior  wall — one  of 
them  reaching  round  to  the 
right  side,  and  one  to  the 
left. 

10  on  the  posterior  wall  —  one 
of  them  reaching  to  the  right 
side,  and  one  to  the  left  side. 

2  on  the  left  side. 

1  on  the  right  side,  and  very 
large. 

3  in     the   fundus  —  one     very 

large. 
23  in  the  anterior  wall — two  very 

large. 
5  in  the  posterior  wall — two  very 

large. 


None  intra-uterine. 

In  100  virgins  consulting  for  some  uterine  disease, 
24  had  fibroid  tumours,  or  one  in  4i.    Of  these  24, 

C  2  on  the  anterior  wall — both  very 
Three  were  pedunculated      .     .      <         large. 

(  1  on  the  posterior  wall. 


Five  were  sessile \ 


Thirteen  were  intra-mural    . 


2    on    the    anterior    wall  —  oae 

large. 
2    on    the   posterior    wall  —  one 

reaching  round  to  left  side. 

1  on  the   right  lateral  wall — and 

very  large. 

11    in   the   anterior   wall — three 
large. 

2  in  the  posterior  wall. 


OF    MENSTRUATION. 


97 


lyro  intra-uterine 


2  to  posterior  wall — and  both  very 

large. 


One  large  fibroid  attached  to  sacrum. 

The  polypoid  fibroids  are  excluded,  because  tliey  are 
considered  separately  in  the  previous  section  on  Polypus. 
Were  thev  included  here,  of  course  the  intra-uteVine 
fibroids  would  be  greatly  increased.  This  arbitrary 
arrangement  is  pathologically  incorrect,  but  practically 
right. 

To  recapitulate — Thus,  of  605  cases  (100  being 
unmarried,  and  505  being  married  and  sterile)  119  had 
fibroid  tumours,  either  large  or  small,  connected  in  some 
way  with  the  uteras,  being  nearly  one  in  5i. 

The  following  table  embraces  the  whole  at  a 
glance : — 


0/ these  119  cases  of  fibroid 
tumour  : — 

14  were  pedunculated    .  . 
46  were  sessile 

Fundus. 

Ant. 
wall. 

Post, 
wall. 

Left 
lateral. 

Eight 
lateral. 

Total. 

.... 

1 
2 
4 

6 
15 
41 

5 

20 
8 
3 

1 
2 

1 

7 

14 
46 

53  were  intra-mural  .... 
3  were  intra-uteiine  .  .  . 



53 
3 

1  was   sacral 

1 
2 

1 

2  were    on  the    posterior 
Up  (o3  tincse) 

2 

Total 

3 

7 

62 

36 

3 

8 

119 

These  tables  show  the  great  frequency  of  fibroid 
growths  in  connection  with  the  uterus,  a  thing  long  ago 
established  by  West  and  others.  It  will  be  seen  that 
(62)  more  than  half  of  the  whole  number  were  seated 
in  or  on  the  anterior  wall. 

It  will  be  remembered  that  I  have  said  (page  84) 

7 


98  UTERINE  SURGERY. 

that  we  find  intra-uterine  polypi  (which  are  only  pedun- 
culated fibroid  tumours)  more  frequently  attached  to 
the  anterior  than  to  the  posterior  face  of  the  cavity  of 
the  uterus.  I  only  state  the  fact  without  pretending  to 
explain  the  why  or  the  wherefore. 

I  give  these  details  simply  because  I  have  them,  and 
not  because  I  attach  much  value  to  such  statistics. 
They  are  entirely  from  cases  observed  in  private  practice. 
Had  I  now  access  to  the  books  of  the  Woman's  Hospital, 
it  is  probable  that  these  figures  might  be  changed,  but 
only  relatively.  Fortunately  for  my  patients  but  two 
of  these  119  cases  were  verified  hj  post  mortem  evidence. 
Their  diagnosis  rests  wholly  upon  the  judgment  of  an 
individual,  which  is  infallible  in  no  man. 

But  I  will  claim,  what  I  would  allow  to  any  one 
else,  that  the  errors  of  judgment  would  be  not  of  fact 
but  of  degree — for  instance,  here  is  a  case  of  fibroid 
tumour  of  the  anterior  wall — it  is  as  large  as  a  Sicily 
orange.  Of  its  situation  and  general  outline  there  can 
be  no  doubt,  but  there  may  occasionally  be  a  case  in 
which  we  are  a  little  doubtful  whether  it  be  intra-mural 
or  merely  sessile.  And  if  the  figures  above  could  be 
varied  in  any  way,  it  would  be  in  some  such  unimportant 
relation  as  this. 

The  diagnosis  of  fibrous  tumours  is  much  more 
certain  now  than  it  w^as  before  the  introduction  of  the 
uterine  probe  by  Dr.  Simpson.  Twenty  years  ago  how 
few  of  us  could  tell  whether  the  uterus  was  anteverted 
or  retro  verted ;  whether  its  enlargement,  if  any,  depended 
upon  a  mere  hypertrophy  of  its  proper  tissue,  or  upon 
some  adventitious  growth  either  within,  upon,  or  near 
the  organ.  Now,  however,  we  diagnose  uterine  compli- 
cations with  the  utmost  precision — and  all  by  the  touch, 
the  tent,  and  the  probe. 


OF  MENSTRUATION.  99 

As  a  rule,  tlae  diagnosis  of  fibroid  tumours  is  not 
difficult.  We  are  more  apt  to  fail  in  detecting  small 
tumours  tlian  large  ones,  and  yet  it  is  easy  to  ma23  out 
very  minute  nodosities  on  the  surface  or  in  the  walls 
of  the  womb.  The  whole  secret  of  this  consists  in 
getting  the  body  of  this  organ  between  the  left  index 
finger  in  the  vagina  and  the  right  hand  in  the  hypogas- 
trium,  as  explained  on  pages  10  and  11,  so  that  every 
portion  of  its  surface  is  minutely  traversed,  and  any 
deviation  from  its  normal  size  is  accurately  measured. 

If  it  be  already  anteverted,  there  is  not  the  least 
difficulty  in  this.  If  it  be  retroverted,  or  even  in  its 
normal  position,  then  it  must  be  brought  sufficiently 
forward  to  be  grasped  between  the  sensive  forces  of  the 
two  hands.  If  the  walls  of  the  abdomen  are  very  thick, 
there  may  be  some  little  obscurity  for  a  while,  but  a 
second  effort  will  usually  clear  it  up.  If  the  patient 
holds  the  breath,  and  contracts  the  abdominal  muscles, 
we  may  be  compelled  to  etherize  her — but  this  is  rarely 
necessary.  But,  suppose  we  have  a  tumour  in  the 
pelvis  the  size  of  a  small  orange,  or  as  large  as  the  fist. 
Is  it  in  the  uterus  ?  on  the  uterus  ?  or  quite  detached 
from  it  ?  The  sound  determines  the  direction  and  depth 
of  the  uterine  cavity,  and  shows  its  relation  to  the 
enlargement,  and  this  in  conjunction  with  the  means  of 
palpation  already  described.  But  even  then  we  may  be 
occasionally  in  doubt  whether  the  enlargement  is  due  to 
something  in  the  cavity  of  the  uterus,  in  its  walls,  or  on 
the  outside — and  here  the  sponge  tent  comes  to  our  aid,^^ 
and  enables  us  to  explore  the  uterine  cavity  by  the 
touch. 

But  suppose  we  have  a  tumour  in  the  Douglas  cul 
de  sac.  We  ask  ourselves  the  questions — Is  it  a  retro 
version  or  flexion  ?     Is   it   merely  hypertrophy  of  thy 


100  UTERINE  SURGERY. 

posterior  wall  ?  Is  it  a  fibroid,  interstitial,  sessile,  oi 
pedunculated  ?  Is  it  a  prolapsed  enlarged  ovary  ?  Is  it 
a  collection  of  pus,  of  blood,  or  of  faeces  ?  The  history 
of  the  case  will  give  the  probable  clue  to  many  of  these 
queries ;  but  the  application  of  the  principles  of  investi- 
gation already  laid  down  can  alone  accurately  solve  the 
real  nature  of  the  malady.  Longer  minute  detail  on 
this  point  would  be  profitless.  Enough  has  been  said  to 
show  the  student  that  positive  knowledge  of  this  charac- 
ter can  be  acquired  only  by  the  ripe  experience  of  self- 
training. 

As  an  illustration  of  the  seeming  difficulties,  but  of 
the  real  facilities  of  diagnosis,  I  here  resort  to  my  best 
argument — a  clinical  report. 

Mrs. ,  from  the  State  of  Texas,  aged  twenty- 
four,  married  five  years,  was  sterile.  Her  menses  were 
regular,  painles^^,  lasting  three  days.  She  had  some 
leucorrhoea,  but  consulted  me  on  account  of  her  sterility. 

She  had  been  treated  by  distinguished  professors  in 
four  of  our  largest  cities,  and  all,  without  exception, 
told  her  she  had  retroversion.  On  making  an  examina- 
tion, I  found  the  opposite  state  of  things,  viz.  a  complete 
ante  version,  with  a  tumour  filling  up  the  Douglas  cul  de 
sac,  and  giving  to  the  touch  the  exact  sensation  of 
density  and  size  of  a  retroverted  uterus,  with  hypertro- 
phy of  posterior  wall. 

But  by  the  method  of  the  consentaneous  counter-pres- 
sure with  the  two  hands,  the  position,  size,  and  relations  of 
the  uterus  and  tumour  were  readily  traced  out  as  shown 
in  this  diagram  (fig.  38).  The  left  index  finger,  after 
exploring  anteriorly  at  «,  was  carried  on  till  it  passed  to 
the  posterior  cul  de  sac  at  h ;  then  the  points  of  the  four 
fingers  of  the  right  hand  were  pushed  firmly  backwards 
and  downwards,  from  e  to  d,  carrying  the  abdominal 


OF   MENSTRUATION. 


101 


walls  from  their  normal  line  at  c  deeply  in  the  direction 
of  the  dotted  line  e  d.  When  this  hand  was  carried 
as  far  in  this  direction  as  could  be  done  with  conve- 
nience  to  the   surgeon    and    comfort   to    the    patient, 


Pig.  38. 


it  was  held  there  immovably  fixed,  while  the  index 
finger  of  the  left  at  b  was  made  to  elevate  the  cervix 
uteri  as  if  to  bring  the  points  h  and  d  into  contact.  If 
the  uterus  be  anteverted,  as  it  was  here,  then  the  fundus 
will  l)e  pushed  up  against  the  palm  of  the  outer  hand  at 
^,  to  be  grasped,  as  it  were,  between  the  two  opposing 
forces,  and  thus  accurately  measured — while  the  same 
discriminating  pressure  detects,  at  the  same  time,  the 
presence  of  the  tumour/.  To  be  more  positive  on  this 
point,  the  index  finger  was  pushed  backwards,  carrying 
the  posterior  wall  of  the  vagina  to  ^,  where  it  was  able 
to  elevate  the  tumour,  passing  it  up  against  the  points 
of  the  fingers  at  d^  while  they  were  still  cognizant  of 
the  presence  of  the  body  of  the  uterus  as  already 
indicated.  This  examination  made  the  case  peifectly 
plain ;  but,  to  fortify  these  facts,  the  finger  was  passed 
into  the  rectum,  which  confirmed,  but  added  nothing  to 


102  UTERINE  SURGERY. 

the  evidence  of  the  previous  method.  A  sound  was 
also  passed  to  the  fundus  of  the  anteverted  uterus, 
which  would  have  removed  all  doubt  if  there  had  been 
any. 

When  I  told  this  lady  what  the  trouble  was,  she 
said  it  must  be  impossible  that  I  should  be  right,  when 
five  or  six  others,  equally  entitled  to  credit,  were  all  of 
an  opposite  opinion. 

I  asked  her  not  to  take  my  opinion  alone,  but  to  go 
to  others  if  she  desired  it,  and  I  gave  the  names  of  three 
or  four  of  our  most  distinguished  accoucheurs  in  New 
York.  In  two  or  three  days  she  returned,  saying  she 
did  not  call  on  any  of  the  gentlemen  I  named,  but  that 
she  had  seen  another  medical  man,  of  deservedly  great 
reputation  as  a  physician,  and  also  of  large  experience 
in  the  treatment  of  uterine  disease,  and  that  he 
pronounced  her  case  undoubtedly  one  of  retrover- 
sion. 

Although  this  case  would  deceive  any  superficial 
investigator,  there  was  nothing  easier  than  its  diagnosis 
by  the  plan  of  bi-manual  palpation.  How  often  have  I 
seen  uterine  examinations  made  by  the  vaginal  touch 
alone !  And  here  is  the  great  mistake.  This  is  very 
well  to  determine  the  size  and  relations  of  the  vagina, 
and  the  condition  of  the  os  and  cervix,  but  so  far  as 
anything  else  is  concerned,  it  is  simply  futile.  It  is 
merely  groping  in  the  dark.  The  value  of  the  uterine 
sound  cannot  be  over-estimated  when  used  merely  for 
purposes  of  diagnosis,  whatever  may  be  said  of  it  as  a 
redresser.  If  we  are  not  able  to  determine  the  position, 
size,  and  relations  of  the  uterus  by  the  touch  alone,  the 
sound  is  infallible  in  giving  us  its  depth  and  direction. 
If  we  find  a  tumour  of  any  sort  either  before,  behind, 
or  to  one  side  of  what  we  usually  regard  as  the  normal 


OF  MENSTRUATION. 


103 


position  of  tliis  organ,  tlie  probe  will  instantly  tell  us  if 
it  be  the  body  of  the  uterus  or  not. 

I  use  the  sound  simply  as  a  probe  to  measure  the 


Pigs.  39  &  40. 

depth  of  the  uterus,  and  to  show  in  what  direction  the 
fundus  lies.  For  this  purpose  I  have  it  made  of  virgin 
silver  or  of  annealed  copper,  silvered.  It  is  also 
smaller  than  Simpson's  sound,  and  without  notches  or 
marks.  It  is  made  malleable  because  it  is  necessary 
to  change  the  curvature  with  almost  every  case.  It  is 
smaller  to  make  it  universally  applicable,  whether  the 
canal  and  os  internum  be  large  or  small.     It  is  without 


104  UTERINE    SURGERY. 

indentations  or  marks,  to  enable  us  to  keep  it  thoroughly 
clean. 

These  two  diagrams  (figs.  39  and  40)  represent  the 
relative  difference  between  a  uterine  probe  of  malleable 
silver  or  copper  and  the  ordinary  redresser  of  hard 
German  silver.  They  represent  the  exact  size  of  the 
instruments  as  found  in  the  shops. 

The  small  one  can  be  curved  to  pass  in  the  suspected 
direction  of  the  body  of  the  uterus,  and,  if  properly 
done,  never  gives  pain  ;  the  other,  large  and  rigid,  often 
produces  great  agony,  sometimes  by  being  too  large 
to  pass  along  a  narrow  canal,  but  oftener  by  being 
forced  in  a  wrong  direction.  Until  I  modified  the 
instrument  to  a  simple  probe,  I  dreaded  even  to  attempt 
its  use  in  any  case  of  suspected  anteflexion.  But  now 
the  diagnosis  of  the  worst  case  of  dysmenorrhoeal  ante- 
flexion is  as  easy  and  as  painless  as  that  of  an  old 
retroflexion  with  a  patulous  canal. 

I  have  often  had  the  greatest  difificulty  with  the 
German  silver  sound ;  and  if  I  were  to  say  I  had  seen 
a  score  of  cases  in  consultation  where  physicians  assured 
me  it  was  utterly  impossible  to  pass  the  sound,  I  would 
not  exaggerate  the  number  in  the  least.  I  have  felt 
and  seen  so  much  annoyance  on  this  point  that  I  may  be 
pardoned  for  a  little  minutiae. 

The  cases  that  usually  give  us  most  trouble  are  those 
of  complete  anteflexion,  with  a  fibroid  in  the  anterior 
wall.  One  will  serve  as  an  example  of  the  class.  Let 
fig.  41  represent  an  anteflexion  with  a  fibroid,  a,  as  large 
as  an  almond,  in  the  anterior  wall.  If  we  should 
attempt  to  pass  the  large  German  silver  sound,  in  its 
fixed  position,  to  the  fundus  uteri,  it  would  inevitably 
be  arrested  at  h,  it  matters  not  how  dexterously  we 
may    elevate    the  fundus    with    the    index    finger    to 


OF   MENSTRUATION. 


105 


straighten  the  organ  up  at 
the  time  we  make  the  effort. 

I  have  seen  such  exces- 
sive pain  thus  inflicted  that 
the  patient  coukl  hardly  be 
persuaded  to  allow  a  repeti- 
tion of  the  process.  And  I 
have  often  passed  the  small 
malleable  instrument  under 
such  circumstances  when  the  ^i*^-  ^i- 

patient  was  not  aware  that  it  had  been  done.  We 
should  never  inflict  pain  if  it  can  be  avoided  ;  nor 
should  we  carelessly  shock  the  nervous  system  of  one  so 
delicately  organized,  and  that  too,  perhaps,  when  that 
organism  is  so  intensified  by  diseased  action  as  to  exag- 
gerate to  an  unbearable  degree  the  slightest  movement 
or  even  sound. 

Valuable  as  the  uterine  probe  may  be  for  giving  us 
the  direction  of  the  fundus  uteri,  it  is  not  to  be  depended 
upon  alone  to  measure  its  depth,  if  that  should  exceed 
four  inches ;  and  for  the  simple  reason  that  the  curva- 
ture necessary  to  pass  it  along  the  pelvian  axes  Avould 
make  it  sti'ike  against  the  anterior  wall  of  the  uterus 
before  it  could  reach  the  fundus,  if  this  should  be  six  or 
eight  inches  deep. 

As  an  illustration,  take  the  followins-  :  A  woman 
thirty-five  years  old,  the  mother  of  two  children,  had 
been  for  several  years  subject  to  menorrhagia.  The 
abdomen  was  about  as  large  as  at  the  full  term  of  preg- 
nancy. Palpation  showed  that  it  was  due  to  an  enor- 
mous tumour,  which  was  either  wholly  uterine  or  uterine 
and  ovarian.  A  physical  exploration  was  necessary  to 
determine  this  point.  The  diagram  (fig.  24)  illustrates 
the  diagnosis. 


106 


UTERINE   SURGERY. 


On  introducing  tlie  uterine  probe,  it  passed  four 
inclies,  striking  the  anterior  wall  of  the  uterus  on  a  line 
with  the  upper  edge  of  the  pubes  ;  but  was  this  truly 
the  whole  depth  of  the  organ  ?     A  gum  elastic  bougie 


Fig.  42 


■would  settle  this  point.  On  making  the  effort,  it  passed 
easily  more  than  eleven  inches  into  the  cavity  of  the 
uterus,  measuring  from  the  os  tincse.  But  it  is  not 
always  easy  to  pass  a  bougie.     If  it  is  large  enough  not 


Fig.  43. 


to  bend  on  itself,  it  may  not  pass  through  some  narrow 
point,  and  so  will  deceive  us.     And  if  it  be  too  small, 


OF  MENSTRUATION.  IQ^ 

it  will  bend  on  itself  in  the  vagina,  and  hence  it  will  be 
difficult -to  pass  it  at  all.  To  overcome  these  objections, 
take  a  bougie  about  No.  6,  sometimes  smaller,  and  run  a 
strong  wire  in  it,  and  give  it  a  gentle  curvature  at  the 
distal  end,  as  shown  in  the  diagram  (fig.  43).  Introduce 
this  just  within  the  os  uteri,  and  then  hold  the  handle 
of  the  wire,  a,  firmly  in  one  hand,  and  push  the  bougie, 
3,  along  it  with  the  other.  The  wire  thus  stiffens  the 
bougie  external  to  the  uterus,  but  allows  it  to  pass 
onwards  to  the  cavity,  taking,  of  course,  the  easiest 
route,  and  measuring  accurately  its  depth.  Whether 
this  direction  be  in  the  central  axis  of  the  organ,  ante- 
riorly or  posteriorly,  would  be  afterwards  determined 
by  the  sponge  tent.  In  this  case  the  bougie  passed 
nearly  its  whole  length  into  the  cavity  of  the  womb, 
marking  a  depth  of  over  eleven  inches.  This  proved 
that  its  enlargement  was  due  to  a  fibroid.  It  was  then 
a  question  whether  this  fibroid  was  intra-mural  or  intra- 
uterine. This  was  proved  at  once  by  a  very  singular 
fact,  viz.  that  the  gum  elastic  bougie,  when  introduced 
into  the  cavity  of  the  uterus,  could  be  felt  through  the 
thin  walls  of  the  abdomen,  and  thinner  of  the  uterus, 
from  just  above  the  pubes,  quite  to  the  fundus  far  above 
the  umbilicus  (see  fig.  42).  Tliis  alone  showed  that  the 
tumour  projected  into  the  cavity  of  the  uterus  from  the 
posterior  wall  of  that  organ.  Was  it,  then,  an  enormous 
fibroid  polypus — i.  <?.,  an  intra-uteriue  pedunculated 
tumour,  or  was  it  a  sessile  fibrous  tumour,  with  a  broad 
attachment  to  the  uterine  walls  ?  The  sponge  tent  was 
to  unravel  that  mystery.  It  was  accordingly  resorted 
to ;  the  finger  was  then  carried  up  into  the  uterus,  and 
the  anterior  portion  of  the  organ  was  found  to  be  free, 
while  on  the  posterior,  about  an  inch  above  the  os  tincaa, 
we  felt  a  large  tense  tumour,  having  attachments  poste- 


103  UTERINE  SURGERY. 

riorly  at  tlie  cervix,  whicli  widened  out  on  either  side 
as  the  finger  was  thrown  in  front  and  around  it.  The 
finger  detected  its  attachment  posteriorly  below,  while 
the  probing  with  the  elastic  bougie  demonstrated  it 
above ;  thus  proving  that  the  tumour  grew  from  the 
posterior  wall  of  the  uterus,  and  that  it  had  a  base  of 
attachment  along  this  wall  of  probably  not  less  than 
eight  or  nine  inches.  The  tumour  itself  was  unusually 
tense  to  the  touch,  and  we  concluded  to  explore  it  by 
puncture.  In  the  presence  of  Dr.  Emmet,  Dr.  Pratt, 
and  Professor  Elliot,  I  passed  a  trocar  into  it  at  its 
lowest  point,  and  in  the  direction  of  its  long  axis,  and 
there  were  discharged  more  than  twenty  ounces  of  a 
colored  serum.  The  puncture  was  enlarged  for  two 
inches,  to  prevent  its  closing.  There  was  at  once  a 
sensible  diminution  in  the  size  and  tension  of  the  abdo- 
men. The  discharge  kept  up  for  some  time  ;  and  this, 
together  with  occasional  injections  into  the  very  fundus 
of  the  uterus,  with  the  liquor  ferri  persulphatis,  diluted 
with  three  or  four  parts  of  water,  arrested  very  promptly 
the  haemorrhages,  and  the  patient  was  dismissed  in  two 
months  in  a  very  comfortable  condition,  and  with 
strength  enough  to  walk  six  or  eight  miles.  Indeed,  so 
far  as  the  haemorrhages  were  concerned,  she  was  cured. 
She  returned  in  a  few  weeks  with  ruddy  looks  to  report 
that  she  was  in  very  good  health,  although  the  abdomen 
was  seemingly  as  large  as  ever.  It  was  evidently  a  fibro- 
cystic tumour,  its  first  element  remaining  in  statu  quo^ 
while  its  second  was  destroyed  by  the  puncture  and 
slitting  up  of  the  cyst.  Within  the  course  of  a  year 
afterwards  this  poor  woman  died  of  cholerine  of  a  few 
hours'  duration,  which  her  physician  did  not  think  in 
any  way  dependent  upon  the  fibroid  tumour. 

We  all  know  that  fibroids  of  the  uterus  are  harmless 


OF  MENSTRUATION.  109 

unless  they  produce  haemorrhage  or  press  injuriously  on 
some  of  the  pelvic  viscera.  I  have  seen  many  cases 
where  there  were  fibroids  larger  than  the  foetal  head,  and 
the  patients  were  not  aware  of  their  existence.  I  was 
consulted  in' Paris  in  October,  1863,  by  a  lady  who  had 
been  married  fifteen  years  without  o0*spring,  and  she 
wished  to  know  the  cause  of  her  sterility.  She  had  a 
pedunculated  fibroid  tumour,  large  enough  to  rest  on 
the  brim  of  the  pelvis,  which  drew  the  uterus  forwards 
and  upwards,  raising  its  fundus  much  above  the  level  of 
the  pubes.  Her  health  was  perfect  in  every  respect,  and 
she  felt  no  inconvenience  from  the  tumour,  which  will 
doubtless  never  shorten  her  life  a  day. 

Of  late  years  a  good  deal  has  been  written  on  the 
treatment  of  fibroid  tumours  of  the  uterus. 

Professor  Channing,  of  Boston,  claims  to  have  cured 
many  by  internal  medication  ;  while  Dr.  Simpson  seems 
to  have  great  faith  in  the  long-continued  use  of  the 
bromide  of  potassium.  Dr.  Emmet  and  myself  have 
tried  this  and  other  constitutional  remedies  in  the 
Woman's  Hospital  and  in  private  practice,  and  I  am 
sorry  to  say  we  have  not  been  as  fortunate  as  the  gentle- 
man named  above.  On  the  contrary,  I  have  never  seen 
the  slightest  eftect  produced  on  such  tumours  by  any 
internal  medication.  Dr.  Atlee,  of  Philadelphia,  and 
Mr.  Baker  Brown,  of  London,  have  each  attacked  uterine 
fibroids  surgically  and  in  a  heroic  way. 

Dr.  Atlee  has  had  a  success  in  enucleation  which  has 
not  been  equalled  by  any  one  else.  He  advocates  a 
total  eradication  of  the  adventitious  growth  ;  while  Mr. 
Baker  Brown  is  satisfied  with  maiming  or  mutilating  the 
tumour  by  what  he  terms  a  gouging  process.  His 
success  has  also  been  very  great,  not  in  curing  the 
disease,  but  in  curing  its  worst  manifestation — haemor- 


110 


UTERINE    SURGERY. 


rhage.  And  with  tbis  we  should  feel  well  satisfied ;  for, 
as  a  general  rule,  I  do  not  think  we  should  interfere 
with  these  tumours  unless  they  endanger  life.  That 
there  are  cases  in  which  we  must  interfere  I  readily 
admit ;  and  the  success  of  Atlee  and  Brown  will  justify 
such  a  course.  I  have  not  been  so  fortunate  as  they  in 
attacking  very  large  intra-uterine  fibroids.  I  have  lost 
two  patients  in  the  Woman's  Hospital  as  a  consequence 
of  operative  procedures ;  one  from  an  attempt  at  enucle- 
ation, the  other  from  the  removal  of  a  bit  of  the  tumour; 


Fig.  44. 

the  one  in  imitation  of  Dr.  Atlee,  the  other  in  imitation 
of  Dr.  Brown.  The  first  was  the  case  of  an  unmarried 
lady,  twenty-eight  years  old.  Menstruation  occurred  at 
sixteen,  and  continued  regular  and  normal  for  ten  j^ears, 
when  it  suddenly  became  abundant  and  painful.  Two 
years  afterwards,  in  November,  1859,  she  was  admits 
ted  to  the  Woman's  Hospital.  The  flow  was  then 
profuse,  exhausting,  and  attended  with  severe  forcing 
pains,  from  which  she  suffered  for  a  whole  week 
before  the  menses  made  their  appearance.     The  uterus 


OF  MENSTRUATION.  lU 

was  about  the  size  of  the  organ  at  the  sixth  mouth  of 
pregnancy.  The  os  and  cervix  were  small,  while  the 
body  of  the  organ  was  large,  hard,  and  roundish.  Its 
outline  and  relations  are  represented  in  fig.  44.  The 
sound  could  be  passed  in  the  direction  of  the  uterine 
cavity  for  only  about  four  inches,  being  arrested  at  a, 
by  striking  against  the  anterior  wall  of  the  uterus.  But 
the  gum  elastic  bougie  showed  that  the  cavity  was  more 
than  nine  inches  deep.  Then  the  sponge  tent  demon- 
strated that  the  tumour  was  intra-uterine,  with  a  broad 
base  of  attachment  to  the  posterior  wall,  beginning  just 
within  the  os,  at  e.  The  great  pain  preceding  and 
attending  each  period;  the  excessive  loss  of  blood  at 
the  time  ;  the  increasing  prostration  ;  and  the  entreaties 
of  the  patient,  determined  me  to  enucleate  the  tumour 
if  possible.  The  first  step  towards  this  was  to  enlarge 
the  canal  of  the  cervix,  which,  as  before  stated,  was 
very  small.  For  this  purpose  it  was  split  widely  open 
up  to  the  insertion  of  the  vagina,  and  even  to  the  os 
internum.  The  haemorrhage  was  very  profuse,  but  ea-sily 
checked.  The  parts  healed  before  the  recurrence  of  the 
next  flow,  which  was  in  no  way  modified  by  the  opera- 
tion. The  forcing  pains  and  the  haemorrhage  were 
quite  as  great  as  before. 

After  this,  the  next  step  of  enucleation  was  taken, 
viz.  cutting  open  the  capsule  of  the  tumour.  Instead 
of  making  a  long  incision  through  this  from  above 
downwards,  as  practised  by  Dr.  Atlee,  I  simply  cut 
the  capsule  transversely  at  ^,  making  an  opening  in  it 
about  two  inches  and  a  half  long,  and  then  passed  a 
sound  for  six  or  seven  inches  in  the  direction  of  the 
dotted  line  e  h,  extensively  lacerating  the  cellular 
tissue  that  bound  the  posterior  wall  of  the  uterus  and 
the  tumour   together.      I  now  think   Dr.  Atlee's  plan 


112  UTERINE   SURGERY. 

of  incisiug  the  capsule  would  liave  been  the  best 
The  bleeding  was  very  profuse,  but  it  was  wholly  from 
the  first  incision,  and  not  from  the  subsequent  lacera- 
tion.    This  was  checked  by  a  tampon. 

After  Miss  M.  recovered  from  the  effects  of  this 
operation,  it  was  thought  advisable  for  her  to  go  to 
the  country,  and  wait  the  efforts  of  nature  in  forcing 
the  tumour  down  through  the  artificial  opening  made 
in  its  capsule. 

She  returned  in  two  or  three  months  with  the  mouth 
of  the  uterus  about  two  inches  and  a  half  in  diameter, 
and  a  portion  of  the  tumour  projecting  through  it  into 
the  vagina.  The  pain  and  the  haemorrhage  were  rather 
worse,  whether  in  consequence  of  the  operation,  or  in 
spite  of  it,  I  do  not  know. 

The  attachments  of  the  tumour  were  now  further 
incised,  and  its  adhesions  extensively  broken  up,  but 
unfortunately  Miss  M.  was  attacked  with  diphtheria, 
from  which  she  barely  escaped  with  her  life.  So  great 
was  her  prostration  from  this  disease  and  the  haemor- 
rhages combined,  that  she  was  again  removed  from  the 
hospital. 

She  returned  six  months  afterwards  (in  October, 
1860),  but  the  haemorrhages  were  in  no  way  modified 
by  the  process  of  enucleation,  which  had  been  slowly 
going  on  for  months.  The  uterus  had  greatly  increased 
in  size,  notwithstanding  the  fact  that  the  tumour,  now 
filling  up  the  whole  vagina,  was  quite  as  large  as  the 
foetal  head  at  full  terra.  Indeed,  it  seemed  that  the 
removal  of  the  obstructions  at  the  cervix  uteri  only 
invited  and  promoted  the  growth  of  the  tumour  down- 
wards, without  dislodging  any  portion  of  it  from  the 
body  of  the  organ.  Its  size  was  so  enormous  that  it 
was  thought  advisable  to  remove  all  that  portion  of  it 


OP  MENSTRUATION.  ^  ]  3 

that  projected  through  the  dilated  cervix,  preparatory 
to  the  real  enucleation  and  ablation  of  what  occupied 
the  body  of  the  womb. 

Accordingly,  a  cord  was  passed  around  it  in  the 
direction  of  the  dotted  line  a 
(fig.  45),  where  it  was  severed. 
The  haemorrhage  was  fearful, 
and  she  lost  a  large  amount  of 
blood  before  it  could  be  con- 
trolled by  a  tampon.  She 
scarcely  rallied  at  all  from  the 
effects  of  the  chloroform,  and 
died  of  exhaustion  in  thirty-six 
hours  afterwards.  ^^^  ^5 

I  think  that  death    in    this 
case  was  caused  by  the  unexpected  and  immense  loss 
of  blood  that  suddenly  took  place  in  the  brief   space 
of  time  between  the  severance  of  the  tumour  and  its 
removal  from  the  vaofina. 

The  prolonged  use  of  the  chloroform  in  all  proba- 
bility exerted  a  very  pernicious  influence. 

The  portion  of  the  tumour  removed  was  so  large  that 
it  was  with  great  dijBBculty  extracted  from  the  vagina. 

Indeed,  to  do  this,  it  was  necessary  to  enlarge  the 
ostium  vaginae  by  perineal  incisions,  one  on  each  side 
of  the  fourchotte.  A  similar  case  to  this  was  operated 
on  at  the  Woman's  Hospital  the  year  before. 

That  part  of  the  tumour  projecting  into  the  vagina 
was  removed  by  ecrasement,  in  October,  1859.  Our 
patient  recovered  from  the  effects  of  the  anaesthesia 
and  the  operation,  and  Ave  expected  to  enucleate  the 
remainder  of  the  tumour,  when  she  was  suddenly 
attacked  with  peritonitis,  four  months  afterwards,  which 
carried  her  off. 

8 


114  UTERINE   SURGERY. 

In  June,  1861,  a  widow  lady,  aged  30,  who  had 
been  for  two  years  sulgect  to  menorrhagia,  was  ad- 
mitted into  the  Woman's  Hospital.  These  periodical 
hsemori'hages  were  profuse  and  exhausting,  and  she 
had  all  the  evidence  of  extreme  ansemia.  The  os 
tincae  was  small,  and  the  cervix  firm  and  indurated, 
while  the  body  of  the  organ  was  felt  to  be  as  large  as 
the  two  fists.  The  depth  of  the  uterus  was  five  inches. 
The  enlargement  and  the  haemorrhage  were  evidently 
due  to  one  of  two  things — either  a  fibroid  tumour 
or  a  polypus.  A  sponge  tent  or  two  enabled  the 
finger  to  pass  into  the  uterine  cavity,  when  a  very 
firm  and  unusually  hard  tumour  was  found  project- 
ing from  the  posterior  wall  of  the  uterus,  having  a 
broad,  strong  attachment  to  its  whole  posterior  surface. 
A  puncture  was  made  in  that  portion  of  the  tumour 
neai'est  the  cervix,  and  a  large  quantity  (eight  ounces) 
of  a  clear,  limpid,  transparent,  straw-coloured  serum  was 
evacuated.  To  make  sure  of  a  radical  cure,  a  bit  of  the 
sac  of  this  fibro-cystic  growth  was  removed  with  scissors. 
It  wa3  elliptical,  and  about  one  inch  and  a  half  long 
by  three  quarters  of  an  inch  wide.  This  was  done  in 
imitation  of  Mr.  Baker  Brown's  gouging  process.  I 
had  seldom  felt  so  well  satisfied  with  an  operation ;  but 
unfortunately  irritative  fever  set  in,  and  my  patient 
died  of  pyaemia  in  the  course  of  twenty  days.  These 
four  cases  are  all  that  have  been  subjected  to  any  opera- 
tion for  radical  cure  in  the  Woman's  Hospital. 

Two  recovered  from  the  operations,  but  both  died 
within  a  year  afterwards — one  from  peritonitis;  the 
other  from  cholerine  of  a  few  hours'  duration.  Two 
died  from  the  immediate  effects  of  operative  pro- 
cedures— one  of  these  from  exhaustion  produced  by 
loss  of  blood  aided  by  chloroform  poisonuig ;  the  other 


OP  MENSTRUATIOIT.  115 

from  pyaemia.  It  may  be  tlius  literally  stated  that  two 
died  and  two  recovered ;  for  death  in  the  last  two  was 
due  to  accidental  causes  which  were  most  probably 
independent  of  the  operations. 

The  coniplete  eradication  of  an  intra-uterine  fibroid 
with  abroad  sessile  attachment  is  exceedingly  hazardous, 
while  the  removal  of  an  intra-uterine  fibroid  with  a 
peduncular  attachment  is  comparatively  one  of  the  safest 
operations  in  surgery. 

But  why  take  so  much  time  with  fibroid  tumours? 
Could  the  removal  of  such  immense  tumours  be  followed 
by  conception  and  safe  delivery  ? 

It  might  very  well  be  a  question,  whether  such  a 
hazardous  operation  as  the  enucleation  of  a  large  fibroid 
tumour  should  be  performed  simply  for  the  removal  of 
sterility,  and  when  the  life  of  the  sufferer  was  not 
jeopardized  by  severe  hseraorrhage.  But  I  could  very 
well  imagine  cases  where  it  would  be  justifiable.  Suppose 
a  dynasty  was  threatened  with  extinction,  and  the  cause 
of  sterility  was  ascertained  to  be  an  enucleable  fibroid: 
here  the  perpetuity  of  a  good  government  and  the 
welfare  of  the  State  might  depend  upon  the  result.  Or 
suppose  an  ancient  family  of  great  name,  influential 
position,  and  large  fortune,  desirous  of  perpetuating 
these  noble  heritages  in  a  line  of  direct  descent :  would 
such  an  operation  be  justifiable,  if  the  parties,  knowing 
the  risks,  were  willing  to  assume  the  responsibilities  ? 

But  could  we  promise  the  possibility  of  conception 
after  all  bad  been  successfully  done  ? 

As  a  rule,  while  there  is  menstruation  there  is 
ovulation,  and  any  woman  that  ovulates  can  be  impreg- 
nated, provided  the  spermatozoa  and  the  ovum  can  be 
brought  in  contact  at  the  proper  time  and  place,  and 
under  favourable  circumstances. 


IIQ  UTERINE    SURGERY. 

The  neck  of  tlie  uterus  may  have  been  destroyed  by 
sloughing,  or  by  other  means  ;  there  may  be  loss  of  the 
greater  part  of  the  vagina ;  there  may  be  partial  atresia 
of  it;  there  may  bean  ovarian  tumour;  there  may  be 
fibroid  tumours,  pedunculated,  sessile,  interstitial,  or 
intra-uterine ;  there  may  have  been  hsematocele,  pelvic 
cellulitis,  or  even  carcinoma  of  the  neck  of  the  womb, 
and  yet  conception  is  always  possible,  provided  men- 
struation, the  sign  and  symbol  of  ovulation,  be  such  as 
to  warrant  a  healthy  condition  of  the  uterine  cavity,  the 
nidus  of  the  new  beino^. 

Our  literature  teems  with  cases  of  delivery  compli- 
cated with  fibroid  tumours  in  some  part  of  the  uterine 
structure,  and  our  experience  and  observation  teach  us 
that  these  tumours  are  a  very  frequent  source  of 
sterility. 

But  to  return  to  the  question — "Is  conception 
possible,  and  safe  delivery  probable,  after  the  enuclea- 
tion and  removal  of  a  large  intra-uterine  fibroid?"  It  is 
not  at  all  uncommon  to  see  this  follow  the  removal  of 
the  intra-uterine  pedunculated  fibroid,  called  polypus — 
and  why  not  the  sessile  fibroid,  called  intra-uterine 
fibroid  tumour  ?  But  the  proof  of  this  is  fortunately  not 
left  to  hypothesis  or  analogy.  And  the  question  is 
answered  affirmatively  by  the  record  of  one  of  the  most 
interesting  cases  to  be  found  in  English  medical  literature, 
by  Mr.  Grimsdale,*  of  Liverpool.  The  interest  of  the 
subject  will  justify  me  in  extracting  the  general  features 
of  the  case  fi'om  Mr.  Grimsdale's  published  account. 


*  A  Case  of  Artificial  Enucleation  of  a  large  Fibroid  Tumour  of  the 
Uterus ;  with  some  Remarks  on  the  Surgical  Treatment  of  these  Tumours. 
By  Thomas  P.  Grimsdale,  Surgeon  to  the  Lying-in  Hospital,  and  Lecturer 
on  Diseases  of  Children,  at  the  Liverpool  Royal  Infirmary  School  of  Medi- 
cine.— Liverpool  Medico  -  Chirurgical  Journal^  January,  1857. 


OF  MENSTRUATION.  Hij 

Oa  the  12tli  October,  1855,  Mr.  Grimsdale  first  saw 
Margaret  West,  aged  33  years,  a  stout  healthy-looking 
woman,  married  three  years ;  eleven  months  after 
marriage  (say  in  1853)  delivered  prematurely  of  a  still- 
born child,  profuse  flooding,  checked  with  difficulty  ;  in 
1854  conceived  as^ain,  but  miscarried  at  three  months  on 
Christmas ;  this  also  attended  with  great  flooding  ; 
menstruation  very  profuse,  but  regular  after  this,  till 
three  months  ago  (say  in  July,  1858)  ;  supposed  herself 
pregnant,  but  there  was  no  nausea.  The  uterus  was 
about  the  size  of  this  organ  at  six  months,  but  without 
the  usual  elastic  feel  of  pregnancy.  A  loud  bruit  heard 
all  over  the  tumour,  cervix  uteri  pushed  forward,  os 
open,  lips  everted,  hard  and  granular. 

Mr.  Grimsdale's  diagnosis  was,  "fibroid  tumour  of  the 
uterus ;  probably  pregnancy  in  addition."  He  watched 
her  for  a  fortnight.  She  had  occasional  profuse  discharges 
of  blood.  On  consaltation  with  Mi'.  Bickersteth,  they 
agreed  that  the  safety  of  the  j^atient  demanded  the  in- 
duction of  abortion  at  once.  Sponge  tents  were  used, 
the  cavity  probed  for  seven  inches,  the  tumour  found  to 
be  adherent  to  the  whole  extent  of  the  posterior  wall. 

Mn  Bickersteth  made  the  incision  for  enucleation 
with  a  straight  bistoury  through  the  posterior  wall  of 
the  cervix,  about  three-quarters  of  an  inch  within  the 
canal,  and,  coming  down  on  the  capsule  of  the  tumour, 
plunged  the  knife  into  it ;  index  finger  passed  through 
incision  nearly  to  the  second  joint,  and  the  tumour  was 
thus  separated  for  some  distance  from  the  proper  tissue 
of  the  uterus.  But  little  bleeding  followed  the  incision, 
which  was  plugged,  the  lint  being  forced  ujd  between  the 
tumour  and  the  uterine  wall. 

l6'^  day  after  operation. — Pulse  96  ;  vagina  hot  ; 
tampon  removed ;  vagina  syringed. 


1]_3  UTERINE    SURGERY. 

2nd  day.  —  Aborted  a.  four  months'  foetus  and 
placenta. 

7/A  day. — But  little  variation  ;  vagina  syringed  and 
opening  plugged  daily. 

'^th  day. — Uterine  pains;  watery  discharge  ;  tumoui 
began  to  protrude  through  the  artificial  opening,  which 
was  dilated  a  little  more;  presenting  part  of  tumour 
soft  ;  discharge  offensive  ;  pulse  120  ;  countenance  pale, 
anxious  ;  tongue  dry  ;  thirst. 

During  the  next  week  her  condition  changed  a  little 
for  the  better.  She  took  beef-tea,  opium,  ergot,  and 
bad'  the  vagina  syringed  twice  a  day.  The  tumour 
gradually  dilated  the  artificial  os,  when,  on  the  14th  day, 
the  fingers  could  not  reach  the  uterus;  the  tumour  had 
passed  through,  so  as  to  fill  the  upper  part  of  the  vagina. 
It  was  soft  and  sloughy ;  pulse  96. 

IMh  day. — Much  worse;  had  a  chill  this  morning  ; 
since  then  very  low;  pulse  112  ;  thready;  tongue  dry  ; 
glazy  ;  countenance  anxious  ;  very  desponding ;  ordered 
brandy  and  beeftea.  9  p.m. — Messrs.  Bickersteth, 
Blower,  and  Fitzpatrick  present ;  pulse  a  little  better, 
but  thrilling  ;  tongue  as  before ;  countenance  bad  ;  put 
her  under  the  influence  of  chloroform,  which  improved 
the  pulse. 

Mr.  Grimsdale  then  passed  his  hand  by  the  side  of 
the  tumour  into  the  cavity  in  the  posterior  uterine 
wall,  and  easily  separated  the  few  attachments  that 
remained  at  its  middle  and  lower  portions.  He  found 
the  great  bulk  of  the  tumour  soft  and  sloughy,  some- 
what like  the  placenta  of  a  child  dead  some  time  in 
utero,  and  already  separate  from  the  uterus.  Pos- 
teriorly, and  high  up  near  the  fundus,  some  firm  fibrous 
bands  passed  from  the  uterus  to  the  tumour,  which 
resisted    all    efforts    to    break    through    them     they 


OF  MENSTRUATION,  1X9 

extended  over  about  three  square  incTies  of  uterine 
surface ;  there  were  eight  or  ten  distinct  bands — one 
as  large  as  the  finger  flattened  out,  and  containing  soft 
sloughy  tissue.  Finding  it  impossible  to  lacerate 
these  bands,  he  held  his  hand  in  the  uterus  till 
Mr.  Bickersteth  went  for  a  large  pair  of  scissors, 
which  occupied  some  thirty  minutes.  Even  then  the 
completion  of  the  operation  was  difficult  and  tedious, 
for  he  says — "  After  continuous  efforts  for  nearly  an 
hour,  I  succeeded  in  dividing  entirely  its  attachments, 
and  removed  the  tumour,  a  sloughy  mass  about  the 
size  of  an  ordinary  placenta."  There  was  no  haemor- 
rhafire,  and  withdrawing:  the  hand  and  the  tumour, 
the  uterus  contracted  down  exactly  as  after  the 
extraction  of  a  placenta,  and  felt  externally  to  be 
about  the  size  of  a  normally  contracted  uterus  after 
an  ordinaiy  labour.  From  this  time  her  restoration  to 
health  was  gradual,  but  sure.  In  a  fortnight  all  fetid 
discharges  had  ceased.  In  two  months  the  uterus  had 
quite  recovered  its  natural  size  and  position,  and  on 
the  sixty-eighth  day  after  the  operation  she  began  to 
menstruate.  It  lasted  four  days,  painless  and  normal 
in  quantity  and  quality. 

So  far  this  case  is  most  interesting  surgically.  If 
Mr.  Grimsdale  had  not  removed  the  decaying,  slough- 
ing mass  as  he  did  on  the  fifteenth  day,  his  patient 
would  evidently  have  died  of  pyaemia  in  a  very  short 
time.  But,  to  me,  the  most  interesting  part  of  the  case 
is  to  be  related. 

The  operation  was  performed  on  the  4th  November, 
1855  ;  the  tumour  removed  on  the  20th.  Menstrua- 
tion returned  on  the  27th  January,  1856;  again  on 
the  25th  February;  and  she  probably  menstruated 
again  about  the   24:th  or  25th  of  March,  for  in  a  foot- 


120  UTERINE  SURGERY. 

note  in  Mr.  Grimsd ale's  report,  be  says,  "  Since  tlie 
above  was  in  type,  I  have  delivered  this  patient  of  a 
Av  ell-grown  eight-and-a-lialf  montlis  child,  stillborn. 
The  membranes  ruptured  suddenly  on  the  17th 
December,  1856.  There  was  a  slight  discharge  of 
blood  soon  after,  but  no  pain  till  the  20th.  At  thi? 
date  the  foetal  heart-sounds  were  heard  distinctly. 
The  OS  dilated  very  slowly ;  the  presentation  was  foot- 
ling; and  there  was  very  inefficient  expulsive  action 
in  the  second  stao'e  of  labour.  On  the  mornina^  of  the 
22  nd  I  got  hold  of  the  left  foot,  and  completed  the 
delivery.  The  child  had  evidently  been  dead  many 
hours,  the  cuticle  of  the  feet  having  begun  to  desqua- 
mate. It  measured  twenty-one  inches  in  length,  and 
was  plump  and  well .  formed.  The  placenta,  large  and 
healthy-looking,  came  away  immediately,  without 
haemorrhage.  The  uterus  contracted  well  and  remained 
so." 

The  evident  bearing  of  this  case  on  the  subject 
under  consideration  is  my  apology,  if  any  were  needed, 
for  giving  so  minutely  its  synopsis  and  sequel.  For  it 
is  a  direct  answer  to  the  question,  "  Is  conception  possi- 
ble and  safe  delivery  j^robable  afcer  the  enucleation  and 
removal  of  large  fibroid  tumours?" 

Before  dismissing  this  subject,  I  may  state  that  Mr. 
Baker  Brown  does  not  now  mutilate  the  fibroid,  but 
satisfies  himself  with  simply  incising  the  os  and  cervix 
uteri.  But  the  most  philosophical  and,  indeed,  the 
most  successful  treatment  of  hsemorrhas^es  fi'om  fibroids 
is  that  of  Dr.  Savage,  of  the  Samaritan  Hospital.  He 
dilates  the  canal  of  the  cervix  with  a  sponge  tent,  and 
injects  the  cavity  of  the  uterus  with  a  solution  of  iodine, 
which  has  been  so  far  both  harmless  and  efficient.  Hia 
f oi'mula  is  this : — 


OF  MENSTRUATION.  121 

5         Iodine 3  i- 

loJ.  Potassium 3  ij. 

Kect.  spt.  wine I  U- 

Water §  vi. 

It  invariably  stops  the  bleeding,  and,  be  says, 
when  repeated  at  each  occurrence  of  the  flow,  for 
five  or  six  months,  the  tumours  undergo  a  sensible 
diminution,  and  in  some  instances  have  entirely  dis- 
appeared. 

I  have  seen  remarkable  results  from  this  treatment 
of  Dr.  Savage,  and  if  the  experience  of  others  should 
be  as  fortunate  as  his,  he  will  have  substituted  a  simple, 
safe,  and  most  successful  method  for  one  fraught  with 
doubt,  difficulty,  and  danger. 

Dr.  Kouth^'  follows  the  plan  of  Dr.  Savage,  but 
substitutes  a  solution  of  the  perchloride  of  iron  for 
the  iodine.  I  have  used  both  agents,  and  the  objection 
that  I  make  to  the  iron  is,  that  while  it  arrests  the 
bleeding  promptly,  by  coagulation,  it  takes  two  or 
three  days  for  the  uterus  to  expel  the  large  masses  of 
coagula,  which  often  provoke  very  severe  forcing  pains. 
Whereas  when  the  iodine  is  used  the  patient  complains 
only  of  a  little  sensation  of  internal  warmth,  which  is 
quite  transitory. 

It  is  very  probable  that  the  curative  process  of 
Mr.  Baker  Brown's  simple  incision  of  the  os,  and  of 
Dr.  Savage's  iodine  injection,  and  Dr.  Routh's  iron,  all 
depend  more  or  less  on  bringing  about  a  degree  of 
subacute  inflammation  in  the  uterine  cavity,  for  I  hear 
from  Dr.  Greenhalgh  that  Mr.  Brown's  operation  when 


*  "  On  some  Points  connected  with  Pathology,  Diagno?is,  and  Treat- 
ment of  Pibrous  Tumours  of  the  Womb  ;  being  the  Lettsomian  Lectures,' 
&c.    By  C.  H.  F.  Roulh,  M.D.,  &c.     London  :  T.  Richards.     1864 


122  UTERINE  SURGERY. 

successful  always  produces  a  great  degree  of  consti- 
tutional disturbance,  with  considerable  tenderness  over 
the  whole  abdomen,  but  especially  in  the  uterine  j-egion. 
I  had  the  opportunity  of  making  a  'post-mortemi 
examination  in  a  case  of  fibroid  tumour,  alluded  to  on 
page  113,  where  the  removal  of  a  portion  of  the  tumour, 
neai'ly  as  large  as  a  foetal  head,  was  followed  by  a  most 
marked  improvement  in  the  haemorrhage.  Indeed, 
after  this  it  could  not  be  called  a  menorrhai^ria.     The 

o 

woman  died  four  months  afterwards  of  an  acute  attack 
of  peritonitis,  lasting  but  a  few  days.  On  opening 
the  abdomen  the  evidences  of  this  suddenly  developed 
and  rapidly  fatal  disease  were  everywhere  visible.  On 
laying  open  the  uterus  there  were  found  strong  old 
adhesions,  here  and  there,  firmly  uniting  the  anterior 
wall  of  the  uterus  to  the  opposite  surface  of  the  tumour, 
which  grew  from  the  posterior  wall. 

These  bauds  of  adhesion  were  in  all  probability  the 
result  of  the  inflammatory  action  necessarily  set  up  in 
the  part  by  the  recuperative  powers  of  nature  after  the 
ablation  of  the  large  vaginal  portion  of  the  tumour,  four 
months  before.  This  probability  is  reduced  to  a  certainty 
when  I  call  to  mind  the  fact  that  previously  to  this 
operation  the  hand  was  several  times,  for  the  purpose  of 
diagnosis,  carried  into  the  uterus,  and  passed  freely  and 
without  obstruction  between  the  contio^uous  surfaces  of 
the  uterus  and  tumour,  where  they  were  now  found 
adherent  in  patches. 

This  condition  of  things  must,  then,  have  been  the 
result  of  the  operation  four  months  before,  and  was 
most  probably  the  cause  of  the  great  improvement  in 
the  menstrual  flow. 

While  we  admit  that  good  results  may  follow  the 
incision  of  the  os  and  cervix   uteri,  after   Mr.  Baker 


OF  MENSTRUATION.  123 

Brown's  plan,  and  equally  good,  with  less  risk,  may 
follow  the  injecting  process,  after  that  of  Dr.  Savage,  1 
believe  we  are  not  in  accord  as  to  their  rationale.  I 
venture  to  suggest  that  they  act  beneficially  by  bringing 
about  the  same  result,  viz.,  an  endo-metritis,  minus  the 
suppurative  stage.  If  this  be  so,  then  we  should  adopt 
the  iodine  treatment  on  theoretical  as  well  as  practical 
grounds,  as  the  one  most  conducive  to  the  production 
of  plastic  or  adhesive  inflammation. 

Dr.  Greenhal2:h  informs  me  that  he  has  had  five 
successful  cases  from  the  iodine  and  sponge-tent  treat- 
ment, combined  with  Recamier's  method  of  scraping  out 
fungous  granulations,  and  that  they  were  all  cured 
promptly  by  a  single  injection  for  each  ;  and  that  both 
he  and  Dr.  Savage  now  use  the  pure  undiluted  ofiQcinal 
tincture  of  iodine,  instead  of  the  solution. 

It  must  not  be  forgotten  that  the  uterine  injection  is 
to  be  always  and  invariably  preceded  by  the  use  of  the 
sponge  tent  ;  that  this  is  an  essential  part  of  the  treat- 
ment, and  ))y  no  means  to  be  neglected,  not  even  if  the 
canal  of  the  cervix  should  appear  to  be  large  enough  to 
permit  the  easy  exit  of  the  fluid.  To  Dr.  Savage  we 
are  particularly  indebted  for  this  practice,  which  renders 
this  operation,  once  most  painful  and  hazardous,  now 
sim23le  and  safe. 

Many  years  ago  I  relinquished  the  practice  of  iuject- 
mg  the  cavity  of  the  uterus,  having  seen  the  most 
violent  and  alarmino:  attacks  of  uterine  colic  follow  the 
injection  of  but  one  drop  of  a  bland  fluid ;  but  now, 
according  to  the  plan  of  Dr.  Savage,  the  cavity  of  the 
uterus  is  made  tolerant  of  any  quantity  of  even  the 
undiluted  tincture  of  iodine. 

Of  Menorrhagia  from  Inversion  of  the  Uterus. — • 


124  UTERINE    SURGERY. 

Inversion  of  the  uterus  is  fortunately  of  rare  occurrence^ 
yet  as  it  may  happen  at  any  time  and  in  the  practice  of 
any  one,  we  shall  devote  some  consideration  to  it.  My 
countryman,  Professor  Charles  A,  Lee,*  has  given  us  a 
very  complete  monograph  on  this  subject.  He  has 
collected  from  various  sources  148  cases,  bemnnino;  with 
the  writings  of  Dr.  Robert  Lee,  and  endino:  with  those 
of  Dr.  Tyler  Smith  and  Professor  White,  of  Buffalo.  I 
would  refer  the  reader  to  this  excellent  paper  for  a  large 
amount  of  most  valuable  information  which  is  condensed 
into  a  few  pages. 

In  many  cases  of  inversion  the  cause  is  said  to  be, 
pulling  on  the  cord.*  It  sometimes  occurs  spontaneously, 
especially  when  the  labour  has  been  very  rapid.  It 
doubtless  occasionally  happens  at  a  period  more  or  less 
remote  after  confinement.  But  I  am  disposed  to  believe 
that  an  adherent  placenta,  particulai-ly  to  the  fundus,  is 
the  most  frequent  direct  cause  of  this  accident,  whether 
the  cord  be  pulled  upon  or  not.  Some  five  or  six  years 
ago,  Dr.  Lewis  A.  Sayre,  Professor  of  Surgery  in  the 
Bellevue  Hospital  Medical  College,  New  York,  showed 
me  a  case  of  inverted  prolapsed  uterus,  which  occurred 
in  a  woman  who  had  never  borne  children.  The  inver- 
sion was  evidently  the  consequence  of  a  fibroid  polypus 
attached  to  the  fundus  by  a  short  thick  unyielding 
pedicle,  which,  as  it  passed  through  the  cervix,  must 
have  drawn  the  fundus  with  it.  This  case  excited  at  the 
time  a  good  deal  of  interest  amongst  the  medical  men 
connected  with  the  hospital,  on  account  of  the  obscurity 
of  its  history  and  the  difficulties  of  its  diagnosis.     The 


*  "A  Statistical  Inquiry  into  the  Causes,  Symptoms,  Pathology,  and 
Treatment,  of  Inversion  of  the  Womb."  By  Charles  A.  Lee,  M.D. — Ameri' 
0X71  Journal  of  the  Medical  Sciences,  October,  1860,  pp.  313  to  363. 


OF  MENSTRUATION,  ;[25 

woman  had  passed  the  time  of  menstruation ;  she  there- 
fore suffered  no  longer  from  hsemorrhages,  but  complained 
only  of  the  mechanical  inconveniences  of  the  proci- 
dentia. 

Dr.  McClintock  describes  a  case  so  exactly  similar  to 
this,  that  the  drawing  of  it  in  his  book  (page  98)  would 
pass  for  an  accurate  representation  of  Dr.  Sayre's 
case. 

Dr.  Lee's  paper  contains  references  to  several  cases 
similar  to  these,  reported  respectively  by  Browne,*  Hig- 
ginSjf  Oldham,  E,igby,  Le  Blanc,  and  Velpeau,  the  last 
four  in  "  Ashwell  on  Diseases  of  Women,"  pp.  403-5. 

Dr.  Alexander  H.  Stevens,  of  New  York,  has  had  a 
chronic  case  of  inverted  uterus  under  observation  for 
more  than  thirty  years.  It  had  existed  for  some  years 
before  he  saw  it.  His  patient  suffered  from  periodi- 
cal hsemorrhages,  which  ceased  with  change  of  life,  when 
the  inverted  organ  diminished  in  size,  as  it  always  does 
at  this  c!'itical  period.  The  fundus  is  now  not  more  than 
half  the  size  that  it  was  during  menstrual  life. 

Dr.  Charles  A.  Lee  J  has  seen  one  of  twenty-five 
years'  duration,  which  had  remained  undetected  till  he 
was  consulted.  The  patient  was  then  forty-five  years 
of  age.  She  had  had  hsemorrhages  at  intervals,  and  wag 
quite  anremic.  In  the  course  of  twelve  months  after- 
wards (March,  1858)  the  menses  ceased,  her  health 
became  vigorous,  and  there  was  no  need  of  surgical 
interference. 

Dr.  Lee  §  quotes  one   case  of  congenital  inversion, 


*  DrtWin  Medical  Journal,  vol.  vi.  p.  33. 

t  Edinburgh  Monthly  Journal,  July,  1849,  p.  889. 

I  American  Journal  of  the  Medical  Sciences,  October,  1860,  p.  340,  case  140 

§  Loc.  cit.,  p.  323. 


126  UTERINE  SURGERY. 

reported  to  tlie  Frencli  Academy  of  Medicine  by  Dr, 
Williame,  of  Metz.  His  paper  also  contains  two  cases 
of  inA'^ersion  occurring  at  an  earlier  period  of  pregnancy. 
One  of  partial  inversion,  reported  by  Dr.  Spae  in  the 
Northern  Journal  of  Medicine^  July,  1845  ;  the  other 
of  complete  inversion  at  the  fifth  month  of  pregnancy, 
by  Dr.  John  A.  Brady,  in  the  New  YorTc  Medical  Times^ 
February,  1856.  But  the  most  remarkable  case  of  this 
sort  is  that  of  Dr.  Woodson,*  of  Kentucky.  The  patient, 
aged  twenty-seven  or  twenty-eight  years,  pregnant  about 
four  months,  was  eno^a^red  in  washing^,  some  distance  from 
the  house,  when  violent  labour  pains  came  on,  and  she 
was  not  able  to  get  home.  She  was  greatly  alarmed, 
felt  the  foetus  protrude  from  the  vagina,  and  took  hold 
of  it  and  forcibly  pulled  it  aw^ay,  which  brought  the 
uterus  entirely  out,  producing  complete  inversion.  She 
tore  oif  most  of  the  placenta  which  was  adherent, 
forced  the  uterus  back  into  the  vagina,  and  did  not  call 
for  medical  aid  for  five  days  afterwards.  Dr.  Woodson 
then  saw  her,  in  consultation  with  the  family  physician  ; 
and  found  the  uterus  inverted,  lying  just  within  the  vagina, 
with  a  portion  of  decomposed  placenta  still  adhering. 
He  ordered  vaginal  washes  and  an  anodyne  for  the  time, 
and  on  the  next  day,  the  sixth  after  the  accident,  he 
succeeded  in  replacing  the  uterus.  The  loss  of  blood 
was  not  great  or  alarming,  although  it  had  continued 
from  the  time  the  accident  occurred. 

The  replacement  of  a  chronic  inversion  was  formerly 
thought  to  be  impossible.     Now,  however,  it  is  proven 


*  American  Journal  of  the  Medical  Sciences,  October,  1860,  Art.  XL, 
"  Complete  Inversion  of  the  Uterus  at  four  months  of  Utero-gestation. 
Replaced  six  days  after  the  accident."  By  E.  W.  Woodson,  M.D,,  of  Wood- 
ville,  Kentucky. 


OF  MENSTRUATION.  127 

to  be  not  only  possible,  but  quite  practicable.  Dr. 
Tyler  Smith  *  replaced  one  after  twelve  years  of  inver- 
sion. It  required  eight  days  with  the  india-rubber 
air-ball  pessary,  conjoined  with  manipulation  night  and 
morning  fop  ten  minutes  at  a  time.  Dr.  Charles  West  f 
has  replaced  one  of  twelve  months'  standing.  He  also 
used  the  graduated  pressure  of  an  india-rubber  air-ball, 
after  Dr.  Tyler  Smith's  plan.  Both  of  these  cases  reco- 
vered. Professor  White,;{  of  Buffalo,  New  York,  replaced 
one  of  fifteen  years'  standing.  The  operation  was  done 
in  fifty  minutes,  under  chloroform.  Unfortunately  the 
patient,  thirty-two  years  of  age,  died  of  peritonitis 
sixteen  days  afterwards.  Dr.  Noeggerath,  §  of  New 
York,  has  succeeded  in  one  case  of  thirteen  years' 
standing. 

This  great  revolution  in  practice  in  the  treatment  of 
chronic  inversion  is  due  to  Dr.  Tyler  Smith,  who  was 
the  first,  I  believe,  in  this  country,  to  demonstrate 
its  practicability,  and  to  Professor  White,  who  was  the 
first  in  America  to  perform  this  operation  successfully. 

I  have  had  but  two  cases  of  chronic  inversion.  In 
one,  the  uterus  was  removed  by  the  ecraseur ;  in  the 
other  it  was  replaced  in  five  minutes  under  the  influence 
of  ether.  One  had  existed  for  nine  months,  the  other 
for  twelve.  One  was  at  the  Woman's  Hospital ;  the 
other  in  private  practice.  The  first  case  was  sent  to  the 
hospital  in  June,  1859,  by  Dr.  Maxwell,  of  Johnstown, 
New  York. 

This  patient,  aged  thirty-nine,  married  five  years,  had 


*  Medical  Times  and  Gazette,  April  24th,  1858. 

t  Medical  Times  and   Gazette,  October  29th,  1859, 

X  American  Journal  of  the  Medical  Sciences,  July,  1858. 

§  American  Medical  Tmes,  April  26th,  1862,  p.  230. 


;[28  UTBRIN'E  SURGERY. 

had  one  miscarriage  and  two  labours  at  full  term,  the 
last  on  the  2Gth  December,  1858.  She  was  in  labour 
nine  hours.  The  pains  continued  very  strong  after  the 
expulsion  of  the  child.  The  placenta  was  retained. 
The  physician  was  obliged  to  remove  it,  and  in  so  doing, 
remarked  that  somethins;  bad  come  down  which  would 
have  to  go  back  again.  The  mother  of  the  patient  saw 
a  large  bleeding  mass  protruding,  which  the  physician 
pushed  up  into  the  vagina.  The  haemorrhage  and  the 
pains  continued  for  nearly  twenty-four  hours  afterwards. 
On  the  next  day  another  physician  was  called  in,  who 
succeeded  in  checking  the  haemorrhage  and  reli'^ving  the 
constant  pains.  About  a  month  after  delivery,  the 
hsemorrhage  suddenly  returned  with  great  force,  but 
was  controlled  by  a  tampon.  From  this  time  she  was 
never  entirely  free  from  more  or  less  Ijsemorrhage,  up 
to  the  time  of  her  admission  to  the  Woman's  Hospital. 
She  was  so  completely  blanched  from  loss  of  blood,  and 
so  exhausted,  that  I  hardly  had  a  hope  of  doing  anything 
for  her  relief.  I  have  seldom  seen  any  one  recover  from 
such  a  state  of  exhaustion.  The  pulse  was  very  rapid 
and  feeble,  the  heart  giving  full  evidence  of  her  anaemic 
condition.  She  could  not  be  raised  up  in  bed  without 
fainting,  and  would  often  faint  while  in  the  recumbent 
posture.  Her  recovery  from  this  condition  was  wholly 
due  to  the  extraordinary  efforts  and  attention  of  Dr. 
Emmet,  whose  eminent  ability  I  have  so  often  mentioned 
in  these  pages.  He  arrested  the  flow  by  a  tampon  of 
the  liq.  ferri  persulphatis  of  Dr.  Squibb ;  he  relieved  the 
disposition  to  frequent  syncope  by  elevating  the  foot  of 
the  bed,  making  it  an  inclined  plane,  and  inviting  what 
little  blood  she  had  to  the  brain  ;  while  by  stimulants, 
tonics,  and  good  nutrition,  a  little  by  the  stomach  and  a 
great  deal  by  the  rectum,  we  had  the  happiness  of  seeing 


OF  MENSTRUATION. 


129 


our  patient  rally  and  gain  blood  and  strength  enough  to 
undergo  operative  procedures.  We  were  afraid  of  chlo- 
roform in  her  enfeebled  condition.  She  was  therefore 
cautiously  etherized.  The  hand  was  then  passed  into 
the  vagina,  the  uterus  grasped,  and  steady  efforts  made  to 
replace  the  organ.  These  efforts  were  continued  for  nearly 
four  hours.  The  uterus  was  partially  replaced ;  that  is, 
it  was  reinverted  to  such  a  degree  as  to  place  the  fundus 
up  within  the  os  uteri,  but  it  could  not  be  passed 
farther.  The  diagram  (ifig.  46)  would  represent  what  I 
mean.  It  took  but  a  short  time 
to  reinstate  the  organ  thus  far, 
but  no  efforts  could  do  more.  A 
tampon,  with  some  s^^ptic  lotion, 
was  applied  to  hold  the  uterus  in 
situ.  And  here  is  where  1  made 
the  great  mistake.  If,  instead  of 
the  styptic  tampon,  I  had  adopted 
Dr.  Tyler  Smith's  plan  with  the 
elastic  air-bag,  the  result  might 
have  been  different.  A  day  or 
two  afterwards,  when  the  tampon 
was  renewed,  I   was  horrified  to 

discover  that  the  vagina,  particularly  at  its  posterior 
cul-de-sac,  had  an  ecchymosed  appearance,  as  if  it  had 
been  stretched  almost  to  the  verge  of  being  ruptured. 
I  am  now  satisfied  that  we  continued  our  eftbrts  for  too 
long  a  time,  although  they  were  not  made  spasmodically. 
The  tampon  was  changed  daily,  the  uterus  being 
retained  as  presented  in  the  diagram.  There  was  no 
pain,  no  haemorrhage,  and  our  patient  ate  and  slept 
well,  and  improved  rapidly  in  looks  and  strength. 

About  eighteen  days  after  this  (July  12th)  Mrs.  R. 
was    placed    again   under   the    influence   of  ethei-,   and 

9 


Fig.  46. 


130  UTERINE  SURGERY. 

another  effort  made  to  replace  the  uterus;  but  after 
an  hour's  time  we  were  obliged  to  desist.  The  late 
lamented  Drs.  Valentine  Mott  and  John  W.  Francis, 
of  the  Consulting  Board  of  the  hospital,  were  both 
present  at  each  trial,  and  they  were  of  the  opinion, 
that  in  this  case  the  entire  ablation  of  the  organ 
would  be  a  safer  operation  than  to  make  another  effort 
to  reinvert  it.  A  few  days  afterwards  menstruation 
came  on,  was  exceedingly  profuse,  and  the  fundus  was 
again  forced  somewhat  into  the  vagiua  in  spite  of  the 
tampon.  The  uterus  was  then  pulled  down  into  the 
vagina,  and  a  strong  ligature  was  passed  round  the 
cervix,  and  firmly  tightened  by  a  small  screw  ecraseur, 
with  the  intention  of  ultimately  removing  the  organ. 
The  ligature  controlled  at  once  the  haemorrhage,  and 
wholly  arrested  the  circulation  of  the  fundus,  as  mani- 
fested by  its  sudden  deep  purple  colour.  But  the  con- 
stitutional disturbance  was  so  intense  and  alarming 
that  we  were  compelled  to  remove  the  ligature  ap- 
paratus at  the  end  of  two  hours.  The  great  pain, 
excessive  nausea,  rapid  pulse,  clammy  skin,  jactitation 
and  pinched  features  were  too  distressing  to  be  wit- 
nessed, much  less  endured,  and  so  the  ligature  was 
removed,  and  opiates  were  freely  given  till  she  was 
entirely  relieved.  A  general  course  of  invigorating 
treatment  was  followed.  Menstruation  in  Aus^ust 
lasted  eleven  days,  but  the  flow  was  not  very  great  at 
any  time. 

After  the  September  menstrual  period,  one  more 
effort  was  made  to  reinvert  the  uterus ;  but  we  could 
effect  no  more  than  is  shown  in  the  diagram  (fig.  46). 

After  this  she  and  her  husband  begged  to  have  the 
organ  removed,  as  we  promised  to  do  it  with  the 
ecraseur  without  "oain. 


OF  MENSTRUATION.  13| 

Accordingly,  on  the  1st  of  November,  she  was 
chloroformed,  and  the  chain  of  the  ecraseur  was  passed 
round  the  cervix,  near  the  os,  and  tightened.  When 
the  operation  was  half  finished,  a  link  parted.  Another 
chain  was  applied,  and  with  this  the  organ  was  cut 
through  ;  but  the  broad  ligament  on  the  right  side  was 
fortunately  not  wholly  severed.  As  the  chain  was  felt 
to  pass  suddenly  through  the  uterine  tissue,  I  was  about 
to  remove  it  and  the  severed  tumour  together,  when  all 
at  once  the  most  fearful  haemon-haa-e  I  ever  encountered 
took  place,  and  in  an  instant  the  vagina  was  full  of 
arterial  blood.  If  the  bleeding  had  been  from  the 
blood-vessels  of  that  portion  of  the  broad  ligament 
ali-eady  severed  and  retracted  within  the  peritoneal 
cavity,  it  would  have  been  beyond  reach,  and,  of  v-ourse, 
our  patient  would  have  died  before  she  could  have  reco- 
vered from  the  effects  of  the  chloroform.  Fortunately, 
the  bleeding  was  from  that  part  of  the  broad  ligament 
still  adherent  to  the  severed  uterus.  Quickly  drawing 
it  forward,  I  passed  the  fore  and  middle  fingers  through 
the  cervix  uteri  into  the  abdominal  cavity,  and  with 
them  compressed  the  remains  of  the  ligament  against 
the  edge  of  the  cervical  opening,  which  promptly 
arrested  the  haemorrhage.  The  blood  was  then  sponged 
out  of  the  vagina,  and  the  undivided  portion  of  the 
broad  ligament  with  the  artery  was  tied ;  after  which  a 
few  sponge  probangs  were  passed  into  the  peritoneal 
cavity,  and  the  blood  that  had  found  its  way  there 
was  carefully  removed.  It  must  not  be  forgotten 
that  the  patient  was  in  the  usual  lateral  semi-prone 
position.  The  divided  edges  of  the  cervix  were 
united  by  ^ve  or  six  interrupted  silver  sutures.  The 
one  on  the  extreme  right  was  made  to  transfix  the 
Ijgated    portion    of    the    broad   ligament,    which    had 


132 


UTERINE   SURaERY. 


"been  drawn  througli  into  the  vagina.  The  edges 
of  the  cervix  united  by  the  first  intention.  The 
opening  through  the  cervix,  before  it  was  closed  by 
the  sutures,  would  easily  have  admitted  the  passage 
of  three  fingers  at  a  time  into  the  peritoneal  cavity. 
This  was  rather  a  fortunate  thing  under  the  circum- 
stances, as  it  afforded  great  facility  for  sponging  out 
the  blood  from  the  peritoneal  cavity.  The  patient 
recovered  rapidly.  Dr.  Emmet  gave  her  opiates  at 
stated  intervals  for  two  or  three  days,  with  good 
nutriment.  She  had  a  small  vaginal  discharge  for  a 
short  time,  till  the  little  projecting  portion  of  broad 
ligament  was  removed.  Ten  days  after  the  operation 
the  bowels  were  opened  by  enemata.  Two  of  the 
sutures  were  cut  off  close,  and  left  to  be  permanently 
sacculated. 

I  have  occasionally  heard  from  Mrs.  R.  since  the 
operation,  and  she  remained  in  good  health. 

This  cut  (fig.  47)  is  copied  from  a  drawing  made 


Fia.  47. 


immediately  after  the  uterus  was  removed.  It  shows 
that  portion  of  the  ligament  in  which  the  bleeding 
artery  was  found.  The  artist  has  slightly  exaggerated 
the  long  diameter  of  the  organ. 


OF  MENSTRUATION".  133 

With   mv  next  case  I  was  more  fortunate.      Ibis 

ft/ 

was  a  case  of  a  lady  in  Springfield,  Massachusetts,  who 
was  attended  in  her  labour  by  one  of  the  most 
eminent  of  our  New  England  practitioners.  I  presume 
it  was  an  'example  of  spontaneous  inversion  at  a  some- 
what remote  period  after  confinement,  for  the  character 
of  the  physician  is  a  suflacient  guarantee  that  it  could 
not  have  resulted  from  any  mismanagement  on  his 
part;  nor  could  it  have  occurred  spontaneously  at  the 
time  of  his  attendance  without  being  detected  by  him 
A  few  weeks  after  this  ladj^'s  delivery,  her  physician 
went  abroad.  Souie  months  afterwards  she  called 
another -physician,  who  treated  her  for  menorrhagia. 
She  did  not  improve ;  and  by-and-by  a  consultation 
was  held,  when  the  case  was  ascertained  to  be  one  of 
inversion. 

She  was  then  etherized,  and  efforts  at  reduction 
were  made,  and  continued  for  an  hour  without  effect. 
Two  or  three  weeks  after  this  I  was  sent  for ;  the 
patient  was  etherized  as  before,  and  I  was  able  to 
reduce  the  inverted  uterus  to  its  normal  relations  in 
less  than  five  minutes.  This  was  in  May,  1860,  about 
twelve  months  after  the  labour.  The  medical  brethren 
present  gave  me  great  credit  for  the  facility  with  which 
the  operation  was  performed.  But  its  speedy  accom- 
plishment was  a  little  accidental.  Introducing  the  left 
hand  into  the  vagina,  I  grasped  the  uterus,  and  soon 
restored  it  to  the  position  represented  by  fig.  46  (page 
129),  where  the  fundus  is  shown  as  just  within  the  os 
uteri.  At  this  moment  I  changed  my  hold  on  the 
uterus,  and,  rather  by  accident  than  design,  deeply 
indented  the  I'ight  cornu,  a^  with  the  thumb  of  the 
left  hand ;  the  fingers  compressed  the  opposite  side  of 
the  organ,  J,  and  while  the  thumb   pushed  the  tissue 


134  UTERINE   StJRaERT. 

in  wliicli  it  was  imbedded  upwards,  the  fingers  rather 
acted  in  a  contrary  direction  on  the  opposite  side ;  and 
to  my  great  surprise,  the  uterus  jumped,  as  it  were,  out 
of  my  hand,  assuming  its  proper  normal  position.  I 
certainly  had  not  the  remotest  idea  of  restoring  the 
organ  under  a  half-hour's  effort. 

The  case  reported  by  Dr.  Noeggerath  was  reduced 
very  much  on  the  principle  of  the  above ;  but  instead 
of  its  being  accidental,  as  with  me,  he  reasoned 
out  the  process  after  he  had  failed  by  the  ordinary 
method. 

As  before  said,  we  are  indebted  to  Dr.  Tyler  Smith, 
of  London,  and  Professor  White,  of  Buffalo,  for  our 
present  success  in  the  treatment  of  inversion  of  the 
uterus.  These  two  distinguished  gentlemen  seem  to 
have  worked  out  the  problem  about  the  same  time,  and 
independently  of  each  other.  Dr.  Tyler  Smith  takes  the 
slower  method  of  persistent  and  gradual  pressure  with 
the  air-bag;  Dr.  White,  the  more  brilliant  but  more 
dangerous  plan  of  immediate  reduction  by  manij)ulation, 
under  the  influence  of  chloroform.  I  fear  that  in  my 
own  country  we  have  been  too  much  captivated  by  the 
eclat  of  sudden  success.  I  am  sure  now  that  it  would  be 
safer  to  combine  the  plans  of  Dr.  Tyler  Smith  and  Dr. 
White. 

I  would  hesitate  a  long  time  before  removing  another 
inverted  uterus. 

Judging  from  the  experience  of  my  two  cases,  the 
great  difficulty  seems  to  be  in  passing  the  fundus  through 
the  OS  internum.  It  was  easy  enough  in  each  instance 
to  reinstate  the  organ  to  the  condition  represented  by 
the  diagram  (fig.  46).  That  being  the  case,  I  should 
infer  that  there  were  no  peritoneal  adhesions  to  prevent 
the  completion  of  the  operation. 


UTERINE   SURGERY. 


135 


There  is  one  point  that  I  wish  to  dwell  on  particu- 
larly. 

Those  who  follow  the  plan  of  my  distinguished 
countryman  Professor  White  (whom  I  have  imitated), 
would  do  well  always  to  make  counter-pressure  with  the 
outer  hand  over  the  abdomen,  as  represented  in  this 
diagram  (fig.  48). 

In  pushing  the  uterus  upwards  by  the  hand  in  the 


Fig.  48. 

vagina,  there  is  certainly  some  danger  of  lacerating  the 
vagina  and  tearing  the  uterus  asunder  from  its  attach- 
ments at  the  posterior  cul-de-sac.  Counter-pressure  will 
obviate  that  danc^er.  Another  advanta^-e  of  counter- 
pressure  is  that  the  fingers  pushed  down  on  the  uterus, 
as  the  cervix  is  doubled  on  itself,  assist  very  materially 
in  dilating  that  portion  through  which  the  fundus  is  to 
be  forced  upwai'ds. 

From  what  I  have  already  said,  it  would  appear  that 
the  reduction  of  an  inverted  uterus  naturally  divides 
itself  into  two  stages  :  the  fii-st,  that  of  pushing  the  body 
of  the  uterus  up  within  the  cervix,  as  represented  in  fig. 


136  UTERINE    SURGERY. 

45  ;  and  the  second,  that  of  completing  the  operation  by 
forcing  the  fundus  through  the  os  internum.  The  first 
stage  is  accomplished  by  directly  pressing  the  body  of 
the  uterus  upwards,  and  putting  the  vagina  well  on  the 
sti-etch,  which,  as  Dr.  White*  says,  ''  pulls  open,  first  its 
mouth,  then  its  neck,  and  finally,  if  persevered  in,  doubles 
the  body  upon  itself  also  ; "  the  second,  by  compressing 
the  fundus  laterally,  and  deeply  imbedding  the  thumb 
in  the  cornus  uteri  (fig.  46,  «),  by  which  means  we  slide 
one-half  of  the  organ  at  a  time  through  the  os  internum 
instead  of  the  whole  fundus,  which  presents  a  greater 
diameter.  Pressure  antero-posteriorly  would  avail 
nothing,  because  we  would  simply  compress  two  flat 
unyielding  surfaces  together  ;  but  the  cornus  can  be 
dimpled  and  forced  inwards  and  upwards  by  the  thumb. 
It  is  useless  to  attempt  this  manoeuvre  till  we  complete  the 
first  stage  of  the  operation. 

I  do  not  think  that,  as  a  rule,  we  should  continue 
our  operative  procedures  more  than  thirty  minutes  at  a 
time.  If  we  fail  to  restore  the  organ  at  once,  then  we 
should  introduce  an  india-rubber  air-bag,  after  the  plan 
of  Dr.  Tyler  Smith,  and  wait  for  our  patient  to  recover 
fully  before  trying  again. 

But  suppose  after  proper  efforts  we  fail  to  restore 
the  uterus,  should  we  amputate  it  ? 

In  the  hands  of  Professor  Channing,  of  Boston,  and 
Dr.  M'Clintock,  of  Dublin,  amputation  of  the  inverted 
uterus  has  proved  to  be  a  very  successful  operation,  and 
one  to  be  justified  if  all  legitimate  means  of  restoration, 
patiently  and  perseveringly  tried,  fail  to  reinstate  the 
inverted  organ. 


*  American  Journal  of  the  Medical  Sciences,  July,  1858,  p.  23. 


OF   MENSTRUATION. 


137 


Fia.  id. 


But  before  taking  this  last  resort,  I  would,  rather 
than  amputate,  make  longitudinal  incisions  from  the  os 
tincae  along  the  cervix  to  a  point  beyond  the  os  internum, 
for  the  purpose  of  facilitating  the 
process  of  reduction. 

I  would  make  at  least  three — 
one  on  each  side,  as  represented  in 
this   diagram    (fig.    49,   a    «),    and 
another    similar    on    the    posterior 
surface.        I     say     posterior     only 
because  it  would  be  easier  to  make 
it  there  than  on  the  anterior  surface 
if  the  patient  be  on  the  left  side,  with 
my   speculum   as    it    is    ordinarily 
used.     The  object  of  these  incisions  would  be  to  divide 
the  circular  fibres  of  the  uterine  tissue,  and  thereby  to 
remove  one  of  the  principal  barriers  to  the  reduction  of 
the  fundus. 

I  hope  I  have  said  enough  to  show  that  we  should 
not  resort  to  the  operation  of  amputation  till  we  have 
tried  persistently  and  patiently  every  possible  means  for 
reinstating  the  organ  to  its  noi-mal  position. 

The  patient  in  whom  I  was  so  fortunate  as  to  restore 
the  organ  after  twelve  months  of  inversion,  subsequently 
conceived;  and  thus  we  see  the  impcTtant  bearing  of 
this  operation  upon  the  subject  of  s.terility.  Even  Dr. 
Tyler  Smith's  successful  case  of  reduction  after  nearly 
twelve  years  of  inversion,  was  followed  by  conception ; 
and  these  two  cases  are,  I  think,  sufiicient  to  warn  us 
against  a  too  hasty  resort  to  the  operation  of  amuuta- 
tion. 

I  have  just  heard  from  Dr.  Tyler  Smith  (July  12th, 
ISCr)),  that  his  patient  ''has  liad  several  children  since 
the  operation  (iu  1856),  and  that  the  medical  man  who 


138  UTERINE   SURGERY. 

attended  lier  in  her  first  confinement  after  the  reduction 
of  the  inversion,  says  that  complete  inversion  occurred 
spontaneously  after  that  confinement,  which  he  readily 
and  at  once  reduced." 

Of  Painful  Menstruation. — Menstruation  may  be 
attended  by  a  general  malaise,  but  should  not,  as  a  rule, 
be  accompanied  by  any  very  severe  degree  of  suffering. 
If  there  is  much  pain,  either  pi-eceding  its  irruption 
or  during  the  fiow,  there  will  generally  be  a  physical 
condition  to  account  for  it,  and  this  will  be  of  a  nature 
to  obstruct  mechanically  the  egress  of  the  fluid  from  the 
cavity  of  the  womb.  The  obstruction  may  be  the  result 
of  inflammation  and  attendant  turaj'escence  of  the 
cervical  mucous  membrane,  whereby  this  canal  becomes 
narrowed  merely  by  the  tumefaction  of  its  lining  coat. 
But  by  far  the  most  frequent  cause  of  obstruction  is 
purely  anatomical  and  mechanical.  For  instance,  the  os 
and  canal  of  the  cervix  uteri  may  be  preternaturally 
small,  or  the  cervix  may  be  flexed  ;  or  these  may  be 
complicated  with  the  presence  of  a  f)olypus,  or  with 
that  of  a  fibroid  tumour,  in  either  the  anterior  or  poste- 
I'ior  wall  of  the  uterus,  and  occasionally  in  the  antero- 
lateral portion. 

Of  250  married  women  who  had  never  borne  chil- 
dren, 129,  or  more  than  half,  had  pain  of  an  abnormal 
kind  attending  the  menstrual  flow.  I  have  been  in  the 
habit  of  dividing  these  into  two  classes,  calling  the  one 
painful,  and  the  other  excessively  painful  or  dysmenor- 
rhoeal.  Of  these  129,  100  were  painful,  or  1  in  2i  of 
the  whole  number  ;  29  were  dysmenorrhoeal,  or  1  in 
8tV«  Of  the  100  painful  menstruations,  58  had  ante  ver- 
sion, or  more  properly  speaking,  anteflexion ;  17  of  these 
had  fibroid  tumours  in  the  anterior  wall :  25  had  retro* 


OF  MENSTRUATION.  I39 

version ;  7  of  these  had  fibroid  tumours  in  the  po  jterior 
wall ;  Jiud  in  17  the  position  was  normal,  one  of  these 
having  a  fil)roid  tumour.  Of  the  29  dysnienorrhoeal 
cases,  23  had  ante  version  ;  14  of  these  had  fibi'oid 
tumours  in' the  anterior  wall :  3  had  retroversion ;  all  of 
these  had  fibroid  tumours  in  the  posterior  wall  :  and  in 
3  the  position  was  normal.  Of  the  100  cases  of  painful 
menstruation,  the  os  was  normal  in  but  6,  unnaturally 
contracted  in  90,  otherwise  abnormal  in  4.  Of  the  29 
cases  of  dysmenorrhoea,  properly  speaking,  the  os  was 
not  normal  in  a  single  case,  being  contracted  in  26,  and 
otherwise  abnormal  in  the  other  3. 

The  following  tabular  statement  presents  the  parti- 
culars at  a  glance : — 


f  Os  was  normal  in  but  . 

^„    ,^„                 „       .   f.  1  i        „       contracted  in     . 

Or    100    cases   or    painiul  men-  l  r~,      ■             n        i  • 

.   ^  <  Lervix  was  liexed  m     . 

struation,  .    ,  . 

'  I            „          congested  in 

(_  There  were  polypi  in 

f  Os  was  normal  in      .     . 

I        ,,       contracted  in     . 

Of  29  cases  of  excessively  pamful^  Cervix  was  flexed  in     . 

menstruation,  j        ^^     iad  polypi  in      . 

(_       „      was  congested  in 


6 
90 
61 

7 
2 

0 

26 

23 

2 

1 


From  this  it  would  appear  that  the  pain  of  menstru- 
ation is  almost  wholly  due  to  mechanical  causes,  for  of 
the  whole  129,  only  8  had  engorgement  or  congestion  of 
the  lining  membrane  of  the  canal  of  the  cervix,  and 
some  of  these  were  complicated  either  with  flexure  of 
the  cervix,  or  with  fibroid  growths  in  some  poi-tion  of 
the  body  of  the  uterus.  I  would  not  deny  that  men- 
Btruation  may  be  painful  merely  from  a  congested  state 
of  the  cervical  membrane,  where  there  is  no  fibroid 
growth,  no  polypus,  no  contracted  os,  and  no  flexure  of 


140 


UTERTXE   SURGERY. 


the  cervix  ;  but  sncli  cases  are  rare,  while  the  great 
majority  of  dysmenorrhoeal  cases  have  a  contracted  os 
and  a  narrowed  cervical  canal  or  a  flexed  one.  In  some 
instances  the  os  is  not  larger  than  a  pin's  head,  or  it  may 
be  large  enough  to  admit  a  No.  4  bougie.  Again,  the  os 
may  be  quite  large  enough,  but  the  canal  may  be  flexed 
so  as  to  form  a  valvular  obstruction  to  the  egress  of  the 
menstrual  fluid.  Sometimes  we  find  the  os  small  and 
the  canal  flexed  without  painful  menstruation,  and  here 
the  cervix  is  not  indurated,  but  soft  and  elastic  to  the 
touch.  Of  the  129  cases  of  painful  menstruation,  but 
20  had  the  uterus  in  its  normal  position,  while  81  had 
anteversion  (31  of  these  with  fibroids  in  anterior  wall), 
28  retroversion  (10  of  these  with  fibroids). 

In  a  great  many  cases,  in  addition  to  a  contraction  or 
flexure  of  the  canal,  the  cervix  will 
be   long,  pointed,  and  indurated. 
If  the  flexure  be  anteriorly,  we  often 
find    the   intra  vaginal  portion    of 
the  cei'vix  unequally  developed — 
that   is,  the    posterior  part,    from 
the  OS  to  the  insertion  of  the  va- 
gina at  a  (fig.  50)  may  be  an  inch 
and  a  quarter  long,  while  the  ante- 
rior, from  the  os  to  the  insertion  of 
the  anterior   cnl-de-sac    at  ^,  may 
not  be  more  than  one-third  as  long. 
The  size  of  the  os  and  the  position  and  relations  of 
the  cervix  may  be  ascertained  by  the  touch,  as  ali'eady 
explained  (p.  9).     But  it  is  well  always  to  resort  to  the 
sound  to  determine  definitely  the  course,  curvature,  and 
contraction  of  the  canal.     To  the  touch  and  the  sight 
the  OS  may  seem  to  be  quite  large  enough,  and  then  we 
may  find   a  flexure,  perhaps  a  very  acute  one,  at  the 


Fig.  50. 


OF  MENSTRUATION.  14  [ 

junction  of  tlie  cervix  and  body  of  the  womb,  due  most 
probably  to  the  presence  of  a  small  fibroid  in  the  ante- 
rior wall  of  the  uterus  (fig.  41,  page  105). 

According  to  the  facts  stated  above,  it  would  seem 
that  the  pathology  of  dysmenorrhoea  is  yet  to  be  written. 
I  am  fully  of  the  opinion  that  it  is  simply  a  sign  or 
symptom  of  disease,  to  be  found  in  some  abnormal 
organic  condition.  This  may  be  inflammation,  or  it 
may  be  the  cause  of  inflammation,  or  it  may  exist 
without  it.  But  whether  inflammatory  or  not,  its 
action  is  mechanical.  I  lay  it  down  as  an  axiom,  that 
there  can  be  no  dysmenorrhoea,  properly  speaking,  if  the 
canal  of  th"  neck  of  the  womb  be  straight,  and  large 
enough  to  ]>errait  the  free  passage  of  the  menstrual 
blood.  In  other  words,  that  there  must  be  some 
mechanical  obstacle  to  the  egress  of  the  flow  at  some 
point  between  the  os  internum  and  the  os  externum,  or 
throughout  the  whole  cervical  canal. 

Dr.  Bennet*  says,  "I  have  always  taught  that 
menstruation  may  be  painful,  even  acutely  painful, 
from  its  dawn  to  its  close,  without  any  mischief  or 
impediment  existing  of  any  kind  whatever."  Many 
years  ago  I  believed  all  this,  simply  because  Dr. 
Benuet  and  others  said  so ;  but  now  I  do  not  believe 
in  any  such  doctrine,  because  experience  has  taught 
me  otherwise.  There  is  no  such  thing  as  what  is 
called  "constitutional  dysmenorrhoea,"  There  was 
a  time  when  we  looked  upon  dropsy  as  an  entity, 
a  disease  in  itself;  but  now  we  know  that  it  is  only 
a  symptom  of  various  diseases.  It  is  a  symptom  of 
disease  of  the  heart,  of  the  kidneys,  of  the  liver;  or  it 
may  follow  haemorrhages  or  diarrhoea.      So  is  it  with 

*  Lancet,  June  24,  1S65,  p.  673. 


142  UTERINE  SURGERY. 

dysmenori'lioea:  it  is  only  a  symptom  of  disease,  which 
may  be  inflammation  of  the  cervical  mucous  membrane  ; 
retroflexion ;  anteflexion ;  fibroid  tumour  in  one  wall 
of  the  uterus  or  the  other;  contraction  of  the  os 
internum  or  os  externum ;  flexures  of  the  canal  of  the 
cervix,  either  acute  or  gently  curved,  either  at  the 
OS  internum,  at  the  insertion  of  the  vagina,  or  extend- 
iuo;  throuo:hout  the  whole  lenojth  of  the  canal :  all 
of  which  are  but  so  many  mechanical  causes  of 
obstruction,  which  must  be  recognized  and  remedied  if 
we  expect  to  cure  the  dysmenorrhoea.  We  do  not 
talk  of  constitutional  toothache,  of  constitutional  colic, 
or  of  constitutional  fractures,  or  constitutional  dis- 
locations. Nor  should  we  speak  of  "constitutional 
dysmenorrhoea."  This  is  but  a  high-sounding  term 
that  means  absolutely  nothing.  The  fact  is,  that  most 
of  the  diseases  of  the  uterus  are  as  purely  sui-gicai 
as  are  those  of  the  eye,  and  require  the  same  nice 
discrimination  of  the  true  surgeon.  And  if  we  fail 
to  detect  the  abnormal  condition  that  produces  dis- 
eased manifestations,  whe'ther  of  sensation  or  secretion, 
it  is  plainly  our  fault.  For  of  all  organs  the  uterus 
is  now  most  subservient  to  the  laws  of  physical  ex- 
ploration ;  and  in  every  case  of  diseased  action,  if  we 
cannot  map  out  accurately  the  peculiar  condition  of 
the  uterus  producing  or  accompanying  it,  it  is  simply 
because  we  do  not  apply  our  knowledge  of  those  physi 
cal  laws  to  its  investigation. 

The  treatment  of  dysmenorrhoea  was  formerly  very 
empirical.  Dewees  cured  many  cases  with  his  ammo- 
niated  tincture  of  guaiacum,  but  I  have  not  seen  any 
one  who  had  derived  the  least  benefit  from  it.  The 
remedy  is  so  nauseous  that  I  could  never  get  a  patient 
to  persevere  with  it.     I  must  confess,  however,  that  of 


OF  MENSTRUATION.  143 

late  years,  since  I  have  learned  more  intimately  the 
nature  of  the  disease,  I  have  not  prescribed  it  at  all. 
My  friend  Professor  E.  D.  Fenner,*  of  Nexv  Orleans, 
has  been  very  successful  with  the  bichloride  of  mercury 
in  minute  doses;  but  I  have  no  experience  with  the 
remedy.  Many  prescribe  belladonna  and  other  nar- 
cotics, but  tliey  can  only  produce  a  merely  palliative 
eifect.  The  operation  of  enlarging  the  canal  by 
incision  is  not  always  successful,  but  it  is  the  only 
procedure  from  which  I  have  derived  the  least  benefit. 
The  whole  philosopliy  of  the  operation  consists  in 
opening  the  canal  and  keeping  it  open,  so  as  to  allow 
the  easy  passage  of  the  menstrual  flow.  M'Intosh 
dilated  the  cervix  with  bougies;  but  whoever  has 
followed  him  must  have  been  struck  with  the  uncer- 
tainty of  the  result,  as  well  as  with  its  painfulness,  to 
say  nothing  of  its  danger.  A  priori^  it  would  seem  a 
trifling  thing  to  pass  a  bougie  along  the  cervix  uteri, 
but  I  have  known  it  to  be  followed  by  most  serious 
results.  In  1859,  Professor  Metcalfe,  of  New  York, 
referred  one  of  his  sterile  dysmenorrhoeal  cases  to  my 
care.  There  was  slight  anteversion,  with  a  small 
fibroid  in  the  anterior  wall.  The  os  was  very  small ; 
the  cervix  long,  pointed,  and  indurated ;  and  the  canal, 
though  straight,  was  very  narrow.  I  advised  the 
operation  of  incising  the  os  and  cervix,  which  was 
objected  to  by  the  lady,  although  Professor  Metcalfe 
w\as  anxious  to  have  it  done.  I  explained  to  her  the 
process  of  dilatation,  and  she  wished  to  try  it. 
Accordingly,  a  small  bougie  was  passed  in  to  the 
depth  of  two  inches,  and  allowed  to  remain  a  few 
minutes.     On  the  next  day  a  larger  one  was  used,  and 

*  New  Orleans  }fedical  News,  1858. 


144  UTERINE    SURGERY. 

in  two  or  three  days  more  a  conical  bougie  was  passed 
dilating  the  os  externum  to  about  a  'No.  9.  She  com- 
plained of  a  good  deal  of  pain  at  the  time,  and  there 
was  a  slight  laceration  of  the  contracted  os.  That 
night  she  had  a  rigor,  followed  by  fever,  and  a  most 
intense  attack  of  metro-peritonitis,  which  lasted  many 
weeks,  and  from  which  she  barely  escaped  with  her 
life.  Her  recovery  was  slow  and  tedious.  This  was 
my  last  bougie  case.  I  have  known  several  cases  of 
the  same  sort  in  the  hands  of  others  in  my  own  country, 
and  I  have  seen  two  in  Paris  during  my  short  sojourn 
there. 

In  November,  1861,  in  Paris,  a  medical  friend  asked 
me  to  see  a  case  of  dysmenorrhosa,  which  was  sterile 
after  a  marriage  of  eight  or  nine  years.  The  os  and 
cervical  canal  were  very  small;  the  cervix  long, 
pointed,  and  indurated.  It  was  just  the  case  for  an 
operation,  or  there  was  nothing  to  be  done.  I  advised 
him  to  incise  the  cervix.  He  was  afraid  of  it,  and  a 
year  afterwards  he  introduced  a  screw  bougie  made  of 
ivory  deprived  of  its  earthy  constituents,  which  was 
allowed  to  remain  in  the  cervix,  and  dilate  it  mechani- 
cally by  absorbing  moisture,  and  expanding  to  twice 
its  original  size.  A  violent  attack  of  metro-peritoniti-s 
was  the  consequence,  and  I  saw  this  lady  when  she 
had  been  ill  about  a  week.  She  had  a  pulse  of  140, 
and  continued  in  a  very  dangerous  condition  for  a  long 
time,  but  eventually  recovered. 

The  other  case  of  metro-peritonitis  from  mechanical 
dilatation  occurred  in  the  hands  of  one  of  the  most 
eminent  physicians  in  Paris.  Fortunately  the  lady 
recovered  after  three  weeks  of  fever,  attended  with 
very  great  suffering. 

This  experience  warns    against    merely   mechanical 


OF .  MENSTRUATION.  145 

dilatation.  But  it  may  reasonably  be  asked,  "Is  it 
more  dangerous  than  splitting  up  the  neck  of  the 
womb?"  I  answer,  "Yes."  I  cannot  now  say  how 
many  hundreds  of  times  (certainly  more  than  five 
hundred)  the  operation  of  cutting  open  the  os  and 
cervix  has  been  done  by  Dr.  Emmet  and  myself  at  the 
Woman's  Hospital  and  in  private  practice,  and  I  now 
remember  but  a  single  instance  in  which  it  was 
followed  by  inflammatory  symptoms,  and  this  resulted 
in  pelvic  cellulitis  and  abscess.  The  case  was  badly 
chosen  for  operation,  and  if  I  had  known  that  this 
patient  had  had  a  pelvic  abscess  once  before,  I  certainly 
should  not  have  operated  on  her.  The  house-surgeon 
of  the  hospital  inadvertently  overlooked  this  part  of 
the  history  of  the  case,  and  hence  the  accident. 

Some  prefer  to  dilate  the  cervix  by  sponge  tents. 
Foremost  amongst  these  stand  the  distinguished  names 
of  Bennet  and  Tilt.  I  have  tried  this  method,  and  the 
results  were  anything  but  satisfactory.  Professor  A.  K. 
Gardner,  of  New  York,  has  used  it  most  extensively  and 
perseveringly,  but  has  now  abandoned  the  practice  as 
unfruitful.  Dr.  Tilt  thinks  the  incision  of  the  cervix 
"an  unjustifiable  operation,"*  and  objects  to  it  because 
it  produces  pain  and  "  flooding  to  an  alarming,  if  not  to 
a  fatal  extent."  As  to  the  pain,  I  am  sure  I  have  seen 
far  more  caused  by  a  bougie  than  I  ever  saw  by  the 
operation.  Indeed  the  operation  is  not  a  painful  one. 
I  have  often  performed  it  on  delicate,  timid  women,  who 
were  conscious  that  something  was  being  done,  but  had 
no  idea  that  it  was  a  surgical  operation.  I  am  opposed 
to  operating  on  any  rational  being  without  first  explain- 
ing: what  is  to  be  done,  and  the  wherefore.     In  the  cases 

*  "  Uterine  Therapeutics,"  p,  255. 
10 


146  UTERINE    SURGERY. 

alluded  to  tlie  operations  were  performed  at  the  sugges* 
tion  and  earnest  wish  of  husbands,  who  feared  that  they 
might  not  be  submitted  to  if  fully  explained. 

In  1858  I  advised  this  operation  in  a  case  of  dys- 
menorrhceal  sterility,  sent  to  me  by  Dr.  Vanderpoel,  of 
Albany,  New  York.  There  was  anteflexion,  with  slight 
hypertrophy  of  tl]e  anterior  wall,  curved  canal,  and 
contracted  os.  The  Doctor  had  tried  the  bougie  system 
for  some  time  without  any  permanent  improvement,  and, 
fully  satisfied  that  an  operation  was  necessary,  he  sent 
his  patient  to  me.  But  the  very  idea  of  cutting  was  so 
terrible  to  her  imagination  that  she  went  to  another 
physician,  who  pronounced  the  operation  "  butcherous  " 
and  dangerous,  and  promised  to  cure  her  by  dilatation 
alone.  Of  course  this  poor  frightened,  nervous  sufferer 
gladly  accepted  the  alternative,  and  at  once  placed 
herself  under  his  treatment.  She  remained  in  New 
York  for  several  months,  undergoing  daily  dilatation, 
and  then  returned  home  without  any  permanent 
benefit.  Thi'ee  months  afterwards  she  consulted  me 
again,  and  on  examination  I  found  the  uterus  just  as  it 
was  seven  or  eight  months  before.  Being  now  fully 
convinced  that  the  operation  afforded  the  only  hope  of 
relief,  she  submitted  to  it.  When  it  was  all  over  she 
could  hardly  believe  it,  and  declared  that  she  suffered 
more  each  time  the  bougie  was  used  than  she  did  from 
the  operation. 

But  so  far  as  mere  pain  is  concerned,  it  might  be  left 
entirely  out  of  the  question  in  these  days  of  anaesthesia. 
When,  however,  we  come  to  speak  of  the  dangers  of  the 
procedure,  I  readily  admit  that  we  may  debate  that 
point.  If,  then,  we  compare  the  dangers  of  the  opera- 
tion with  those  of  mechanical  dilatation,  I  do  not  hesi- 
tate  a  moment  to  declare  the  former  much  the  safer 


OF  MENSTRUATION  _[4'J' 

w]n\e  in  permauent  results  it  is  infinitely  superior.  For 
A'^hilel  liave  frequently  known  pelvic  cellulitis  to  follow 
the  use  of  the  bougie  and  the  tent,  I  have  never  seen  it 
but  once  after  the  operation ;  and  while  the  bougie  and 
the  tent  can  only  produce  temporary  improvement,  we 
know  that  the  operation  is  often  followed  by  a  perfect 
and  persistent  cure.  But  it  may  be  asked,  is  there  no 
risk  in  the  operation?  The  only  trouble  that  I  have 
encountered  is  haemorrhage ;  but  that  was  in  ray  early 
operations,  and  before  experience  taught  me  that  there 
was  any  danger  to  be  apprehended.  Now,  however,  I 
have  no  such  accident,  because  I  take  pains  to  guard 
against  it.  When  Dr.  Simpson  first  published  on  the 
subject,  he  said  he  never  had  hsemori-hage  or  other 
unfavourable  result,  either  directly  or  secondarily ;  so 
that  I  was  emboldened  to  perform  the  operation  at  my 
house,  and  allow  patients  to  ride  home  afterwards.  But 
I  was  soon  undeceived  on  this  point,  for  in  the  short 
space  of  two  mouths  I  had  five  cases  of  haemorrhage  that 
were  truly  alarming.  One  occurred  in  a  lady  residing 
in  Jersey  city,  who  rode  a  distance  of  five  miles  in 
stages  after  the  operation.  The  bleeding  began  just  as 
she  arrived  at  her  home.  She  was,  of  course,  very 
much  alarmed,  and  sent  immediately  for  me,  and  also 
for  her  family  physician,  w^ho,  being  near  by,  soon 
arrived,  removed  the  dressing,  re  tamponed  the  vagina, 
and  arrested  the  bleeding  promptly,  before  I  made  my 
frightened  appearance.  The  other  cases,  though  nearer 
to  me,  were  equally  alarming.  I  then  made  up  my 
mind  never  again  to  operate  on  patients  in  the  consulting 
room.  I  asked  Dr.  Simpson,  when  I  w^as  in  Edinburgh 
in  August,  1861,  if  the  operation  was  still  as  safe  in  his 
hands  as  he  had  at  first  represented  it,  telling  him,  at 


148 


UTERINE  SURGERY. 


the  same  time,  my  experience,  when  lie  declared  that  he 
never  had  any  trouble  from  bleeding. 

How  to  account  for  this  difference  in  our  experience 
I  could  not  imagine,  unless  it  should  be  that  I  cut  more 
extensively  than  he  did.  To  satisfy  my  mind  on  this 
score  Dr.  Simpson  kindly  invited  me  to  witness  the 
operation  in  his  hands.  It  was  the  case  of  a  lady  from 
some  of  the  British  possessions.  The  os  was  small ;  the 
canal  narrow ;  the  cervix  long,  pointed,  and  indurated. 
It  was  precisely  the  case  to  justify  the  operation,  for  the 
gristly  induration  of  the  cervix  rendered  any  other 
method  quite  out  of  the  question.  The  operation  was 
performed  with  the  Doctor's  usual  dexterity.  Then  a 
camel's  hair  pencil,  saturated  with  a  solution  of  the  per- 
chloride  of  iron,  was  thrust  into  the  vagina  two  or  three 
times,  and  in  ten  or  fifteen  minutes  from  the  time  we 
entered  the  lady's  apartment,  we  were  in  the  street 
making  other  visits.  He  had  such  confidence  in  the 
operation  and  in  his  styptic  that  he  did  not  wait  for 
consequences.  Before  the  operation,  he  requested  me 
to  examine  the  condition  of  the  cervix  uteri  by  the 
touch,  and  I  found  it  as  already  described.  After- 
wards I  I'epeated  the  touch,  and  found  the  cervix  as 
thoroughly  divided  from  the  os  externum  to  the  os 
internum  as  it  was  possible  to  do  it,  proving  that  the 
difference  in  our  experience  as  to  haemorrhage  did  not 
depend  upon  any  difference  in  the  extent  of  the 
operation.  I  do  not  pretend  to  account  for  the  fact, 
that  the  operation  is  not  followed  by  haemorrhage  in 
Scotland  while  it  is  in  America ;  and  I  would  warn  my 
own  countrymen  to  take  every  precaution  against 
its  occurrence,  as  it  is  almost  the  only  accident  that  can 
attend  this  operation. 

I  may  be  pardoned  for  pressing  this  subject  a  little 


OF  MENSTRUATION.  149 

farther.  I  look  upon  this  operation,  simple  as  it  is  as 
one  of  the  great  surgical  advances  of  the  day ;  and  I  am 
BO  well  satisfied  of  its  merits,  that  I  would  warn  young 
men  to  be  careful  not  to  bring  it  into  discredit  by 
permitting  an  accidental  complication  that  should  never 
under  any  circumstances  be  allowed  to  take  place.  I 
know  a  most  talented,  promising  young  ph3^siciau  in  my 
own  country,  whose  reputation  was  well  nigh  ruined  by 
blindly  following  authority,  and  operating  with  the 
belief  that  there  was  no  danger  from  bleeding.  Having 
been  taught  to  look  upon  the  operation  as  a  trifling  one, 
devoid  of  all  risk,  he  unguardedly  operated  on  his 
patient  at  his  own  house,  and  allowed  her  in  a  few  hours 
afterwards  to  ride  home,  a  distance  of  four  or  five  miles. 
Haemorrhage  unfortunately  supervened ;  the  doctor  was 
sent  for;  he  was  not  at  home.  Some  time  elapsed 
before  he  could  be  found,  and  when  he  reached  his 
patient  she  was  in  a  collapse  from  loss  of  blood  from 
which  she  never  recovered.  This  is  the  only  well- 
authenticated  case  of  death  from  hgeraorrbage  that  I 
have  known  to  follow  this  operation.  Of  course  it  could 
not  have  happened  but  for  the  overweening  confidence 
of  the  surgeon  in  the  innocuousness  of  the  operation,  and 
it  should  never  happen  again.  Such  an  accident  as  this 
may  be  smothered  up  in  a  great  city,  but  if  it  occurs  in 
the  hands  of  a  country  practitioner,  it  may  wholly  ruin 
him  for  ever. 

The  case  above  alluded  to  happened  in  a  small 
country  village,  and  the  public  excitement  may  be 
imagined  when  everybody  began  to  discuss  the  subject, 
and  to  censure  a  noble  young  physician  for  causing  the 
sudden  death  of  a  citizen  who  was  supposed  to  enjoy 
the  most  vigorous  health.  An  eminent  professor  of 
obstetrics  testified  that  the  operation  was  a  recognized 


150  UTERINE  SURGERY. 

justifiable  one;  that  it  liad  been  well  done,  and  that 
death  was  the  result  of  a  rare  and  unexpected  accident. 
This  testimony  was  corroborated  by  others,  and  thus  the 
popular  indignation  was  appeased,  aud  the  young 
practitioner  reinstated  in  public  confidence. 

But  it  may  be  asked,  is  there  no  other  danger  ?  I 
can  only  here  reiterate  what  I  have  before  stated,  that 
out  of  the  hundreds  operated  on  in  the  Woman's  Hospital 
and  in  my  private  practice,  I  have  seen  but  the  one  case 
of  pelvic  cellulitis  already  noticed,  which  is  the  only  risk 
of  the  operation  that  I  know  of.  While  this  has 
occurred  but  once  in  my  hands  from  the  operation,  it 
has  happened  frequently  under  my  observation  as  the 
result  of  mechanical  dilatation  by  bougies  and  sponge 
tents. 

The  position  I  take  is  this :  that,  as  a  rule,  the 
operation  is  less  painful  than  the  use  of  the  bougie, 
which  must  be  repeated  for  months ;  that  it  is  entirely 
devoid  of  danger  from  haemorrhage,  provided  we  exer- 
cise ordinary  prudence  in  the  after-treatment ;  that  it  is 
less  frequently  followed  by  pelvic  infiammation  than 
either  the  bougie  or  the  sponge  tent ;  that  it  is  more 
certain  and  permanent  in  its  results  than  either  or  both ; 
and  that,  if  we  exclude  it,  there  are  great  numbers  of 
curable  cases  which  would  be  placed  beyond  the  pale  of 
treatment.  Thus,  from  my  stand-point  of  view,  the 
operation,  when  indicated,  is  always  to  be  j^referred  to 
any  and  all  other  means  of  enlarging  the  cervical 
canal. 

I  am  sur23rlsed  to  find  that  this  operation  is  so  seldom 
performed  in  Great  Britain  out  of  Edinburgh.  In 
London  it  is  condemned  by  the  great  body  of  the  profes« 
sion,  although  performed  by  several  eminent  men.  But 
where  we  find  one  man  to  uj^hold  it,  we  may  point  to 


OF  MENSTRUATION.  15| 

scores  who  oppose  it.  This  cannot  long  remain  so ;  foi 
where  honesty,  intelligence,  and  earnest  inquiry  reign 
supreme,  as  they  do  here,  the  truth  must  and  will 
prevail. 

On  the 'Continent,  so  far  as  I  know,  this  operation  is 
ahnost  completely  ostracized.  When  I  went  to  Paris  in 
September,  1862,  a  lady  of  very  high  position  asked 
my  opinion  in  reference  to  her  sterility.  She  had  been 
married  thirteen  years  without  issue.  On  examination, 
I  was  convinced  that  conception  could  never  by  any 
possibility  occur  unless  the  neck  of  the  womb  were  well 
opened  by  incision.  All  sorts  of  mechanical  dilatation 
had  already  been  fi-uitlessly  emj^loyed,  producing  metro- 
peritonitis, and  leaving  the  os  and  cervix  as  contracted 
as  at  the  beginning.  When  the  husband  asked  me, 
''What  are  the  risks  of  the  operation?"  I  replied,  "In 
America  or  England  nothing  but  hsemorrhage,  and  that 
we  control.  I  cannot  say  what  they  would  be  in  Paris, 
for  here  you  have  erysipelas  often  following  the  most 
trifling  wounds.  Ask  your  own  sui-geon  about  it." 
They  sent  for  my  friend  Professor  Nelaton,  who  said 
that  in  France  the  operation  would  be  attended  with 
great  risk  to  life.  Such  a  decision  from  such  an 
authority  of  course  put  the  operation  wholly  out  of  the 
question  for  the  time  being.  However,  soon  after  this  I 
had  the  good  fortune  to  meet  Sir  Joseph  Olliffe,  who 
invited  me  to  perform  the  operation  on  one  of  his 
patients  in  the  upper  ranks  of  life.  When  I  told  him 
what  I  have  related  above,  he  said  he  was  perfectly 
familiar  with  British  and  American  literature  on  the 
subject,  and  knowing  the  safety  of  the  operation,  would 
assume  all  responsibility  in  the  matter.  This  operation, 
the  first  of  the  sort  that  I  did  in  Paris,  was  performed 
on  the   31st  of   October,  i8G2,  for  Sir  Joseph  Ollill^, 


152  UTERINE  SURGERY. 

His  patient  recovered  without  the  slightest  trouble ;  and 
on  the  2nd  of  Decembei"  we  operated  on  the  lady  whose 
case  was  first  mentioned.  To  guard  against  any  risk 
from  the  atmosphere  of  Paris,  we  w^ent  to  their  chateau, 
not  many  leagues  from  the  city.  The  case  got  well 
rapidly,  as  usual,  and  conception  fortunately  occurred 
seven  or  eight  months  afterwards.  She  is  now  (Septem- 
ber, 1865)  the  happy  mother  of  two  beautiful  children, 
— one  a  boy,  sixteen  months  old  ;  the  other  a  girl,  less 
than  a  month  old ;  and  this  after  a  sterile  marriage  of 
thirteen  years.  I  am  a  little  minute  in  this  merely 
historical  part  of  the  introduction  of  the  operation  into 
France,  for  I  wish  to  show  that  it  may  be  done  as  well 
and  as  safely  there  as  elsewhei'e. 

My  third  case  was  that  of  a  native,  and  I  went  with 
her  to  the  country  to  perform  the  operation.  The  next 
was  an  American,  operated  on  in  Paris;  then  another 
American  ;  and  then  I  began  to  operate  on  natives  of 
Fj'ance,  and  in  the  city  of  Paris,  "with  the  same  fearless- 
ness that  I  did  on  Americans. 

I  may  be  excused  for  these  minute  details ;  for  as 
the  operation  was  condemned  by  the  highest  authority 
in  France,  it  was  important,  not  so  much  for  myself  as 
for  the  advancement  of  surgery,  that  I  should  exercise 
every  precaution  to  guard  against  accident  or  untoward 
results.  I  have  performed  this  operation  twenty-four 
times  on  the  Continent  without  accident,  except  the 
occurrence  of  haemorrhage  in  one  case  on  the  sixth  day 
after  operation,  which  was  promptly  controlled  by  Sir 
Joseph  Olliffe  in  my  absence.  My  patients  varied  in 
age  from  twenty-two  to  forty.  They  were  natives  of 
France,  Vienna,  Frankfort,  England,  Scotland,  Ireland, 
and  the  United  States.  The  operations  were  performed 
in    the  autumn,  winter,  spring,  and  summer.  "  Twenty 


OF  MENSTRUATION.  ]^53 

were  done  in  Paris,  two  near  Paris,  and  two  at  Baden ; 


and  in  all  there  was  tlie  same  rapid  and  safe  recover}^ 
from  the  eftects  of  the  operation  as  I  had  always  seen  in 
New  York.  Of  course  this  small  number  of  successful 
operations  is  not  enough  to  establish  fully  its  acclimatiza- 
tion and  its  claims  to  universal  favour  there  ;  but  they 
are  certainly  sufficient  to  attract  the  notice  and 
consideration  of  the  profession  in  France. 

But  we  were  speaking  of  painful  menstruation  and 
its  almost  invariable  concomitants,  contracted  os  and 
narrowed  cervical  canal ;  and  having  said  so  much  in  a 
general  way  about  the  various  methods  of  overcoming 
these,  we  may  now  proceed  to  discuss  the  plan  of  ope- 
rating, together  with  the  after-treatment  necessary  to 
protect  against  hsemorrhage  and  to  ensure  a  patulous 
canal. 

For  the  operation  of  incising  the  os  and  cervix  uteri, 
we  are  indebted  to  Dr.  Simpson.  His  method  is  followed 
by  most  operators,  both  in  my  country  and  in  this.  He 
places  his  patient  on  the  left  side,  introduces  the  index 
finger  of  one  hand  into  the  vagina,  pushes  the  fundus 
uteri  up  if  it  be  ante  verted,  passes  his  uterotome  (fig.  51) 
along  the  cervix  through  the  os  internum,  springs  the 
blade,  and  withdraws  the  instrument,  cutting  open  one 


Fig.  51. 


side  of  the  cervix  ;  then  reintroducing  the  instrument, 
the  other  side  is  cut  in  like  manner  ;  thus  making  a 
l)ilateral  incision  of  the  cei'vix  large  enough  to  allow  the 
index  finger  to  be  passed  to  the  os  internum ;  and,  as 


154 


UTERINE    SURGERY. 


before  stated,  he  tlien  passes  into  the  vagina  a  large 
camePs-hair  pencil,  saturated  with  a  solution  of  the 
perch loride  of  iron. 

Dr.  Greenhalgh  has  modified  Dr.  Simp' 
son's  instrument  by  giving  it  two  blades, 
which  cut  through  both  sides  of  the  cervix 
at  once,  thus  ensuring  an  equilateral  unifor- 
mity of  section  that  cannot  always  be  predi- 
cated of  the  single-bladed  instrument.  His 
instrument  (fig.  52)  is  a  masterpiece  of 
ingenuity,  and  answers  well  in  his  j)rac- 
tised  hands.  But  I  ol)ject  to  both  these 
methods,  because  they  are  done  in  the  dark, 
and  too  much  is  left  to  the  execution  of  a 
machine  instead  of  the  judgment  of  the 
geon. 

Suppose  it  were  necessary  to  amputate 
an  elongated  uvula, — by  no  means  an 
uncommon  operation, — would  it  be  judi- 
cious to  run  one  finger  down  the  throat  and 
guide  by  it  some  machine  for  performing 
the  operation  in  the  dark?  Or  would  it 
be  more  surgical  and  more  precise  to  look 
into  the  throat,  seize  the  part  with  a  proper 
appliance,  and  amputate  it  where  our  judg- 
ment would  determine  to  be  rio:ht  and  best 
for  the  individual  case?  There  are  ope- 
rations that  must  be  done  by  the  touch 
alone  ;  but  we  never  select  this  plan  if  it 
be  possible  to  aid  the  manipulatory 
process  by  the  sight. 

Besides  the  objections  already  urged 
against  instruments  of  this  class,  there  is  another  to 
which  all  instruments  on  the  principle  of  cutting  from 


Fig.  52. 


OF  MENSTRUATION.  155 

above  downwards  are  obnoxious — viz.,  that  as  the  ute- 
rus is  not  fixed,  it  may  glide  upwards  to  some  extent 
by  the  mere  centrifugal  force  of  the  expanded  blade  or 
blades,  and  thus  we  can  never  feel  altogether  certain  of 
the  lenofth  and  breadth  of  the  cut.  Whether  too  much 
or  too  little,  it  is  not  safely  remediable  afterwards. 

The  operation,  as  I  prefer  to  perform  it,  differs  from 
Dr.  Sim|)son's,  not  in  its  aim  and  scope,  but  merely  in 
its  mechanical  execution.  He  and  his  followers  operate 
in  the  dark ;  I  bring  everything  plainly  into  view. 
They  cut  from  within  outwards ;  I,  in  the  contrary 
direction,  from  the  os  externum  upwards  to  the  cavity 
of  the  womb.  They,  as  a  rule,  do  not  tampon  the 
vagina  after  the  operation ;  I  always  do,  for  the  double 
purpose  of  guarding  against  haemorrhage  and  ensuring 
an  open  os. 

I  place  the  patient  on  the  left  side,  as  for  all  the 
operations  in  uterine  surgery.  The  speculum  (fig.  5,  p. 
18)  is  introduced  ;  a  small  tenaculum  is  hooked  into  the 
central  portion  of  the  anterior  lip  of  the  os  tincse ;  the 
uterus  is  gently  pulled  forwards ;  one  blade  of  a  pair  of 
curved  scissors  is  passed  into  the  canal  of  the  cervix  till 
the  outer  one  comes  almust  in  contact  with  the  insertion 
of  the  vagina  on  the  side  of  the  cervix,  and  the  portion 
thus  embraced  is  divided  at  one  blow  of  the  scissors. 
Then  the  opposite  side  is  in  like  manner  divided,  and 
the  operation  is  almost  finished  (fig.  53).  It  only 
remains,  while  the  uterus  is  still  held  in  position  by  the 
tenaculum,  to  sponge  away  the  blood,  and  pass  a  narrow- 
bladed,  blunt-pointed  knife  (at  a  proper  angle  with  its 
handle)  and  divide  the  small  amount  of  tissue  on  each 
side)  leading  from  the  scissor-cuts  up  to  the  very  cavity 
of  the  womb.  The  scissors  never  cut  the  whole  amount 
of  tissue  embraced  between  the  blades.   They  will  spring 


156 


UTERIXE    SURGERY 


"back  a  little,  making  only  a  deep  notch  on  each  side  of  the 
OS.     The  advantage  of  cutting  the  edges  of  the  os  with 


Fig.  53, 


scissors  is  that  we  make  the  incisions  perfectly  equilateral 
and  symmetrical. 


Fig.  54 

[I  now  often  use  scissors  with   short    straight    blades,  but   curved   above  the 
joint,  as  here  sho\vn.] 

Fig.  55  represents  the  knife  with  the  blade  in  proper 
position  for  cutting  the  left  side  of  the  canal.  To  cut 
the  right  side,  it  is  necessary  to  turn  the  blade  in  the 
opposite  direction,  as  shown  by  the  dotted  line.  The 
blade  may  be  fixed  firmly  at  any  angle  by  the  screw 
at  the  end  of  the  handle,  which  drives  a  shaft  up 
into  little  holes,  as  seen  in  fig.  56,  w^here  the  razor-shape 
of  the  blade  is  also   shown.     The  operation  is  quickly 


OF   MENSTRUATION. 


157 


Fig.  55. 


Fig.  56. 


done,  and  the  judgment , 
of  the  surgeon  deter- 
mines whether  the  pe- 
culiarities of  the  case 
demand  more  or  less  cut- 
ting. The  haemorrhage  is 
usually  unimportant,  but 
sometimes  it  is  profuse; 
and  I  have  occasionally 
seen  it  come  with  such  a 
rush  that  the  vagina  would 
be  filled  before  a  set  of  sponges 
could  be  washed  out.  But  there 
is  nothiiis:  to  be  feared.  Press  one 
or  two  sponge  probangs  (fig.  57) 
right  into  the  neck  of  the  uterus, 
but  at  the  same  time  be  sure  to 
keep  the  organ  firmly  fixed  by  the 
tenaculum  ;  for  if  the  bleeding  be 
profuse,  it  is  a  very  awkward  and 
unlucky  thing  to  let  it  slip  out,  par- 
ticularly if  the  vagina  is  lax  and 
deep.  A  minute  or  two  will  usu- 
ally suffice  to  control  the  bleeding  by  the  pressure  of 
the  probangs.  When  that  is  done,  the  dressing  may 
be  proceeded  with.  Two  or  three  small  pieces  of  cot- 
ton, large  enough  when  moistened  to  fill  up  the  gaping 
OS,  are  to  be  thoroughly  saturated  with  water,  then 
squeezed  as  dry  as  possiljle,  and  afterwards  wetted 
in  a  mixture  of  one  part  of  Deleau's  neutral  solution  of 
the  perch loride  of  iron  with  four  or  five  parts  of  water, 
or  in  Dr.  Squibb's  liq.  ferri  persulphatis  similarly  dilut- 
ed. Squeeze  out  the  superfluous  fluid,  and  place  a  })it 
of  the  cotton  in  an  angle  of  the  wound,  pressing  a  por- 


158 


UTERINE  SURGERY. 


tion  of  it  up  into  the  cervical 
canal,  and  holding  it  in  place 
with  the  sponge  probang. 
Apply  another  bit  of  cotton 
similarly  prepared  on  the  op- 
posite side,  and  press  it  down 
with  another  sponge  probang- 
If  necessary,  another  portion 
of  cotton  may  be  placed  cen. 
trally;  then,  if  there  is  no 
bleeding,  some  cotton  wet 
with  water  or  glycerine,  may 
be  laid  over  the  neck  of  the 
womb,  to  be  covered  with  dry 
cotton  to  the  extent  of  sup- 
porting the  whole  dressing 
neatly  and  comfortably  iii  its 
place.  The  patient  is  put  to 
bed,  having  been  perhaps  five 
or  six  minutes  on  the  table. 
She  eats  and  drinks  as  usual,  but  the  recumbent  pos- 
ture is  enjoined  for  a  few  days.  She  may  pass  water 
lying,  or  it  may  be  drawn  off.  The  only  object  of 
the  recumbent  posture  is  to  ensure  the  retention  of  the 
dressing  in  situ.  I  formerly  allowed  my  patients  to  sit 
up  and  walk  about  the  I'oom  the  day  after  the  opera- 
tion ;  but  I  Avas  so  often  annoyed  by  the  supervention 
of  haemorrhage  that  I  at  length  adopted  the  plan  of 
keeping  them  down  till  the  spontaneous  separation  of 
the  intra-cervical  dressing. 

On  the  day  after  the  operation,  the  whole  of  the 
vaginal  portion  of  the  tampon  is  to  be  carefully  removed  ; 
placing  the  patient  in  the  position  as  for  the  operation, 
and  using  the  speculum,  which  must  be  introduced  so  as 


Fia.  57. 

[This  cut  is  introduced  here 
simply  to  show  the  mechanism  of 
the  sponge-holder,  and  the  proper 
size  of  the  sponge.  We  often  use 
too  large  a  sponge  to  be  passed 
with  ease  into  the  cervix.  We 
should  have  a  few  much  smaller 
than  this.] 


OF  MENSTRUATION.  159 

not  to  derange  tlie  relations  of  the  dressing.  When  it 
is  all  removed  down  to  the  intra-cervical  portion,  a  wad 
of  cotton  saturated  with  Price's  glycerine,  and  large 
enough  to  cover  completely  the  cervix  and  its  first  dress- 
ing, is  laid  over  it,  and  the  patient  again  lifted  into  bed. 
The  action  of  this,  as  already  fully  explained,  is  to 
induce  a  profuse  watery  discharge  from  the  vagina,  which 
keeps  the  part  cleanly  drained  of  all  secretions  or  exuda- 
tions from  the  decomposition  of  the  blood  contained  in 
the  original  dressing.  This  glycerined  cotton  is  to  be 
removed  and  renewed  daily  till  the  suppurative  process 
throws  off  the  dressins:  from  the  neck  of  the  womb.  This 
will  not  be  under  three  or  four  days.  In  the  mean  time 
the  glycerine,  by  its  detergent  and  antiseptic  properties, 
keeps  everything  sweet  and  clean  ;  and  its  affinity  for 
water,  which  by  osmosis  it  extracts  from  the  tissues  with 
which  it  lies  in  contact,  keeps  the  parts  entirely  clear  of 
any  secretion  that  might  be  re-absorbed  and  poison  the 
blood,  if  not  thus  drained  off  by  the  cheinico-capillary 
action  of  the  dressing.  No  one  can  thus  apply  glycerine 
to  the  neck  of  the  womb  and  not  be  struck  with  its 
peculiar  power  and  properties.  The  intra-cervical  dress- 
ing will  be  loosened  on  the  third  day  or  later,  and  it 
may  then  be  gently  removed  with  forceps.  If  it  adheres 
obstinately,  let  it  alone,  but  cover  it  and  the  whole 
cervix  with  the  cotton  glycerole,  and  at  the  next  dress- 
ing it  may  come  away  easily.  I  have  frequently  provoked 
bleeding  by  a  little  impatience  in  removing  it  prema- 
turely. When  it  is  once  safely  out,  then  the  cervix  is  to 
be  plugged  with  a  small  bit  of  cotton  glycerole,  and  the 
whole  covered  as  before  with  the  same.  This  dressing 
is  to  be  renewed  daily  till  the  parts  have  entirely  healed, 
which  usually  takes  from  twelve  to  seventeen  days,  or 
perhaps  till  the  recurrence  of  the  next  menstrual  period 


IQQ  UTERINE   SURGERY. 

And  this  reminds  me  that  the  operation  should  always 
be  performed  within  from  three  to  five  days  after  a  men- 
strual epoch,  so  that  we  may  have  time  enough  for  the 
healing  process  to  be  wholly  completed  before  the  recur- 
rence of  the  next  period. 

There  is  sometimes  great  trouble  in  keeping  the 
mouth  of  the  womb  sufficiently  open.  It  never  remains 
just  as  we  cut  it.  The  tendency  of  all  cicatrizing  wounds 
to  contract  as  they  heal  is  wonderfully  illustrated  here. 
I  have  often  been  amazed  to  find  the  os  contracted  in 
a  month  to  one-foui'th  of  the  size  of  the  original  incisions. 
I  have  frequently  seen  it  cut  open  large  enough  to  admit 
the  index-finger  up  to  the  os  internum,  and  then  close  in 
a  few  weeks  to  such  a  degree  as  not  to  admit  a  No.  4  or  5 
bougie,  and  this  in  spite  of  persevering  eiforts  to  prevent 
the  contraction.  This  is  the  case  where  there  is  great 
induration  of  the  cervix,  with  deposits  of  fibrous  tissue. 
I  have  frequently  been  compelled  to  repeat  the  opera- 
tion, and  I  remember  several  patients  upon  whom  I  have 
operated  as  often  as  three  times  in  the  course  of  a  few 
months,  and  even  then  the  result  was  not  wholly  satisfac- 
tory. These  may  be  called  exceptional  cases,  but  it  is  well 
to  know  that  they  are  not  very  rare.  Even  when  the  os 
tincse  remains  open  enough,  we  may  have  some  trouble 
in  keeping  the  contracted  portion  above  of  normal 
dimensions.  This  may  be  the  case  if  there  is  much  of 
a  flexure,  particularly  anteriorly.  And  here  I  would 
recommend  the  occasional  passage  of  a  bougie  after  the 
first  week.  Dr.  Emmet  is  in  the  habit  of  using  the 
sound  as  early  as  the  third  day  after  the  operation, 
passing  it  into  the  cavity  of  the  womb,  and  pressing  it 
pretty  firmly  first  against  one  side  of  the  canal  and  then 
aci^ainst  the  other  in  withdrawins;  it.  I  have  in  a  few 
cases  followed  his  example,  but  with  a  little   timidity. 


OP  MENSTRUATION. 


161 


Dr.  Greeuhalgh  uses  a  self-retaining  intra-utei 
which  is  very  ingenious,  and  an- 
swers well  in  his  hands.  Dr. 
Priestley's  instrument*  (fig.  58) 
may  be  foijnd  useful  under  these 
circumstances.  Introduced  as  an 
ordinary  sound,  it  is  then  dilated 
as  shown  in  the  cut. 

Incision  of  the  os  often  cures 
dysmenorrhoea  ;  sometimes  it  only 
modifies  it.  And  again,  I  have 
seen  cases  where  it  produced  no 
beneficial  effect  whatever.  The  first 
menstrual  flow  after  it  is  usually 
ushered  in  without  the  premoni- 
tions that  had  so  long  harassed 
the  poor  sufferer,  and  she  may  pass 
through  the  whole  period  with 
comparative  comfort  ;  but  I  think 
it  advisable  for  such  patients  to 
take  very  good  care  of  themselves 
at  each  return  of  the  flow,  and  to 
avoid  all  unnecessary  exposure  or 
fatigue.  If  there  is  pain  enough 
to  lie  down,  I  direct  an  anodyne 
by  the  i-ectum,  and  for  this  purpose 
McMunn's  elixir  of  opium  is  the 
very  best.  It  is  less  apt  to  nau- 
seate or  to  produce  headache  than 
crude  opium  or  any  of  its  alka- 
loids. It  is  more  efficacious  by  the 
rectum  than  by  the  mouth,  because 


•ine  stem. 


Fig.  5 


*  Medical  Times  and  Gazette,  March  5th,  1864. 
11 


IQ2  UTERINE  SURGERY. 

it  is  more  immediately  in  conjunction  with  tlie  ner\  es  of 
the  affected  part. 

Bat  suppose  the  bilateral  incision  produces  no  per- 
manent amelioration,  are  we  to  give  up  the  case  as 
beyond  the  reach  of  surgery  ?  By  no  means.  We  must 
then  reinvestigate  ;  for  there  may  still  be  some  mecha- 
nical obstacle  undetected,  or,  if  detected,  unrelieved  by 
the  operation.  For  instance,  dysmenorrhcea  may  persist 
m  consequence  of  an  undetected  polypus,  or  of  acute 
flexure  with  contraction  of  the  canal  of  the  cervix  at  the 
OS  internum ;  or  it  may  be  the  result  of  a  curvature  of 
the  cervix,  at  the  insertion  of  the  vagina,  with  elonga- 
tion of  the  intra  vaginal  portion,  and  a  consequent 
unequal  development  of  its  anterior  and  posterior  seg- 
ments. I  propose  to  give  examples  of  each  of  these 
classes. 

I  have  on  more  than  one  occasion  found  the  pain  to 
be  due  to  an  undetected  polypus,  so  diminutive  as  to 
elude  observation.  A  single  illustration  will  serve  as 
an  example  of  its  class,  and  at  the  same  time  be  a 
warning  and  a  guide  to  the  inexperienced. 

Mrs. ,  aged   thirty-two,  married  at  twenty-four, 

sterile,  had  dysmenorrhcea  for  some  years  before 
marriage,  worse  after.  Her  sufferings  were  excru- 
ciating for  about  two  hours  on  the  second  day.  She 
had  in  the  course  of  twelve  years  been  treated  by 
sixty  different  physicians  without  permanent  benefit, — 
the  largest  number  I  ever  knew  any  one  person  to 
consult.  She  had  been  under  the  care  of  many  of  the 
most  eminent  men  in  at  least  five  or  six  of  the  great 
capitals  of  Europe,  besides  her  consultations  at  home. 
I  saw  her  in  January,  1857.  Her  general  health  was 
good ;  her  only  trouble  seemed  to  be  the  much  dreaded 
dysmenorrhcea. 


OP  MENSTRUATION.  J 53 

The  uterus  was  of  normal  size  and  in  proper  position. 
Os  and  cervix  both  small,  but  not  indurated.  I  re- 
Bortied  to  the  sponge  tent,  but  found  no  polypus,  no 
fibroid,  and  no  flexure  of  the  canal.  Three  days  after 
(January  12),  the  os  presented  precisely  the  same 
appearance  that  it  did  before  the  use  of  the  tents. 
The  next  menstruation  was  quite  as  painful  as  usual, 
if  not  more  so.  As  the  canal  was  straio:ht,  and  tlie 
cervix  soft,  I  would  hardly  have  expected  severe  pain, 
although  the  os  was  rather  small.  Yet  I  did  not 
know  what  else  to  do  but  to  incise  the  os  and  cervix, 
hoping  that  some  benefit  might  be  derived  from  it. 
Accordingly,  the  operation  was  performed  on  the  22nd 
January,  and  the  parts  were  healed  before  the  next 
menstrual  period;  but  the  pain  was  still  the  same, 
and  so  continued  for  three  or  four  months,  in  spite 
of  treatment.  I  was  now  quite  perplexed.  I  had 
used  the  sponge  tent  and  found  no  polypus.  I  had 
then  enlarged  the  cervical  canal  without  the  least  im- 
provement ;  but  the  symptoms  were  so  evidently  those 
of  mechanical  obstruction,  that  I  concluded  to  make 
another  exploration  of  the  cavity  of  the  uterus.  I 
accordingly  introduced  a  small  sponge  tent,  and  on 
its  removal  I  passed  another,  larger  and  long  enough 
to  enter  the  cavity  of  the  womb.  On  its  removal, 
I  had  the  satisfaction  of  finding  and  bringing  away 
a  polypus,  which  was  but  little  larger  than  a  common 
garden  pea.  Its  attachment  and  relations,  represented 
in  the  diagram  (fig.  59),  suggest  at  once  the  rationale 
of  the  symptoms. 

The  violent  agonizing  pain  always  supervened  on 
the  second  day  of  the  flow.  When  I  first  felt  the 
tumour,  it  Avas  protruding  through  the  os  internum 
after   the   removal  of  the   tent ;  but   by  the  pressure 


164 


UTERINE   SURGERY. 


Pig.  59. 


of  tlie  finger  it  suddenly  slipped  upwards,  and  1  could 

not  touch  it  again  till  the  fin- 
ger was  gently  forced  through 
the  OS  internum  to  the  fundus, 
when  I  fortunately  seized  it  with 
forceps  and  brought  it  away. 

My  explanation  of  the  pain 
is  this — By  the  second  day  coa- 
gula  formed  above  the  tumour, 
which  pressed  it  downwards,  its 
slender  pedicle  yielding  till  it 
blocked  up  completely  the  os 
internum  just  like  a  ball-and- 
socket  valve.  Then  would  come 
the  violent  neuralo^ic  throes  con- 
tinning  for  two  hours  or  more, 
till  the  tumour  either  dilated  the  contracted  part,  or 
was  compelled  to  retreat  again  into  the  uterine  cavity 
by  displaced  coagula  driven  between  it  and  the  poste- 
rior face  of  the  uterus  by  the  expulsive  efforts  of  the 
organ. 

The  case  illustrates  the  necessity  of  a  very  thorough 
investigation  before  a  correct  diagnosis  can  always 
be  made  out  in  obscure  c;)ses.  The  leeching,  the 
physicking,  the  blistering,  the  anodynes,  the  baths, 
the  mountain  excursions,  the  sea-bathing  and  sea 
voyages  that  this  poor  patient  suffered  and  endured 
for  years  are  almost  incredible.  As  contemptible  as 
the  little  polypus  was,  it  took  me  nearly  four  months 
(shall  I  say  ?)  of  empirical  observation  to  find  out  that 
it  was  the  source  of  all  the  mischief. 

It  is  now  plain  enough,  but  the  difficulties  of  dia- 
gnosis may  be  appreciated  when  we  remember  the 
history    of    the    case   and   the   great   number   of  dis- 


OP  MENSTRUATION.  Ig^ 

tinguisTied  physicians  who  were  baffled  in  their  honest 
efforts  to  elucidate  it. 

I  have  already  sai(i  that  sometimes  after  the  cervical 
canal  is  freely  opened  by  the  bilateral  incision  it  con- 
tracts again,  and  the  pain  of  dysmenorrhoea  may  be 
just  as  severe  as  before  the  operation,  and  that  this  is 
more  apt  to  be  the  case  if  there  is  much  flexure, 
particularly  anteriorly.  We  shall  then  in  all  proba- 
bility be  compelled  to  repeat  the  operation,  and  exer- 
cise greater  care  in  keeping  the  canal  open  afterwards. 
We  may  occasionally  find  the  obstruction  at  the  os 
internum  with  flexure  and  contraction,  while  the  lower 
portion  of  the  canal  may  be  of  normal  size.  This, 
however,  is  by  no  means  common.  Yet  I  have  seen 
several  examples  of  it.  Its  most  perfect  type  I  found 
in  a  patient  of  Sir  Joseph  Olliffe.  This  lady  was  about 
thirty-six  years  of  age,  and  had  suffered  from  painful 
menstruation  most  of  her  menstrual  life.  Sir  Joseph 
had  dilated  the  os  externum  and  the  cervix  up  to  the 
OS  internum,  but  had  never  been  able  to  pass  a  sound 
through  this.  One  of  the  most  eminent  surgeons  of 
Paris  saw  her  in  consultation  with  Sir  Joseph  about 
four  years  ago,  and,  failing  to  pass  the  sound,  proposed 
to  enlarge  the  contracted  portion  by  the  use  of  the 
actual  cautery  !  This  treatment  was  not  carried  out,. 
and  on  my  arrival  in  Paris,  in  the  fall  of  1862, 
Dr.  Olliffe  kindly  invited  me  to  see  her.  I  found  the 
fundus  lying  just  behind  the  inner  face  of  the  symphysis 
pubis,  with  quite  a  sharp  flexure  at  the  os  internum. 
The  sound  could  be  easily  passed  to  the  os  internum, 
where  it  met  with  an  unyielding  barrier,  and  I  was 
obliged  to  have  a  small  one  made,  quite  probe  like, 
just  to  suit  the  case ;  and  even  this  could  not  be  passed 
with  the  patient  on  the  back ;  but  by  placing  her  on  the 


166 


UTERINE    SURGERY. 


side,  using  tlie  speculum,  and  fixing  the  cervix  with  a 
tenaculum,  it  passed  into  the  uterine  cavity  seemingly 
through  a  dense  inelastic  ring  of  fibrous  tissue,  which 
resisted  not  only  the  ingress  but  the  egress  of  the 
olive-shaped  point  of  the  probe.  I  at  once  agreed 
with  Sir  Joseph's  opinion  that  an  incision  of  the  part 
was  the  only  safe  and  speedy  method  of  overcoming 
the  difiiculty.  The  neck  of  the  uterus  was  split  bila- 
terally, just  as  if  it  had  been   contracted  all  the  way 

to  the  OS  tincae.  When  we 
came  to  cut  the  gristly  circular 
band  at  a  (fig.  60),  the  blunt- 
pointed  knife  was  passed 
throusrh  it  with  some  little 
difiiculty,  and  the  cuts  on  each 
side  were  attended  with  the 
peculiar  creaking  sensation  that 
we  experience  in  cutting 
through  cartilage.  The  wound 
was  treated  in  the  usual  way, 
as  previously  laid  down,  and  all 
was  well  by  the  time  of  the  next  menstruation.  The  os 
internum  was,  after  the  fourth  or  fifth  day,  foi'cibly 
pressed  open  laterally  by  the  sound,  as  practised  by  Dr. 
Emmet. 

But  the  pain  of  menstruation  may  continue  even 
after  all  our  best  efforts  to  enlarge  the  os  internum  as 
well  as  the  cervical  canal  by  the  bilateral  incision.  It  is 
then  often  the  consequence  of  curvature,  with  elongation 
of  the  vaginal  portion  of  the  cervix,  accompanying  ante- 
flexion. When  this  is  the  case,  we  shall  find  the  os 
tincse  looking  in  the  direction  of  the  axis  of  the  vagina, 
the  posterior  portion  of  the  cervix  from  the  os  tincae  to 
the  posterior  cul-de-sac  being  two  or  three  times  as  long 


Fig.  60. 


OF   MENSTRUATION. 


167 


Fig.  61. 


as  the  anterior,  measuring  from  the  os  to  the  anterior 
cul-de-sac.  I  have  repeatedly  performed  the  bilateral 
operation  on  such  cases  as  this  without  improvement, 
and  for  the  best  of  reasons.  If  we  take  a  flexible  tube 
the  size  of  the  cervical  canal,  and  curve  it  as  represented 
by  the  diagram  (fig.  61),  it  flattens  out  laterally,  and 
the  inner  concavo-convex  surfaces, 
necessarily  brought  into  close 
apposition,  present  an  almost  val- 
vular mechanical  obstacle  to  the 
passage  of  a  fluid  in  either  direc- 
tion. By  referring  to  the  diagram, 
it  will  be  seen  at  once  that  a  bila- 
teral incision  could  only  widen  the 
canal  a  little  transversely,  but  not 
at  all  antero-posteriorly  ;  that  the 
curvature  would  remain  the  same, 
and    consequently     the    distances 

between  the  two  opposing  surfaces  of  the  cervical  canal 
would  in  no  way  be  modified  by  such  operation. 
Having  so  often  failed,  under  such  circumstances,  to 
afford  the  relief  anticipated  from  the  bilateral  incision,  I 
at  last  devised  and  practised  the  following  method.  To 
remove  the  flexure  of  the  canal  would  be  to  remove  the 
obstacle  to  the  easy  passage  of  the  menstrual  flow.  To 
do  this,  it  is  only  necessary  to  split  the  posterior  portion 
of  the  cervix  from  the  os  tincse  in  a  straisrht  line  back- 
wards,  nearly  to  the  insertion  of  the  vagina,  and  thus  the 
canal  of  the  cervix  is  made  to  run  in  a  strais^ht  line  from 
the  cavity  of  the  uterus  to  the  terminus  of  the  incision 
at  <z,  instead  of  curving  round  to  the  os  tincse.  The 
method  of  doing  this  is  very  simple.  The  patient  as 
usual  on  the  left  side ;  the  speculum  introduced ;  the 
anterior  lip  of  the  os  tincse  is  held  by  the  tenaculum,  as 


168 


UTERINE   SURGERY. 


•^ 


SO  often  described ;  and  then  with  a  straight  pair  of 
scissors  the  posterior  portion  of  the  cervix  is  split  at  one 
blow,  as  far  as  can  be  easily  and  conveniently  done  by 
scissors,  which  would  be  about  as  far  as  represented  by 
the  dotted  line  a  <?,  fig.  61.  Then  the  blunt-pointed 
knife  (fig.  62),  bent  at  a  proper  angle  with  its  shaft,  and 
cutting  backwards,  is  passed  up  to  the  cavity 
of  the  uterus,  and  the  part's  cut  in  the 
direction  of  the  line  a  d^  thus  straighten- 
ing out  the  canal,  and  thereby  removing 
the  mechanical  obstacle  due  to  its  flexure. 
Fig  63  is  intended  to  represent  the 
second  stage  of  the  operation.  The  uterus 
is  firmly  fixed  by  the  tenaculum,  while  the 
razor-shaped  blade  of  the  blunt  knife  is 
seen  in  the  act  of  cutting  the  canal  back- 
wards. The  case  is  to  be  treated  on  the 
same  general  principles  laid  down  for  the 
management  of  the  bilateral  operation. 
There  is  some  little  care  necessary  to  avoid 
cutting  through  the  vaginal  cul-de-sac  into 
the  peritoneal  cavity — an  unpardonable 
blunder  that  no  true  surgeon  could  possibly 
make.  The  operation  has  succeeded  admi- 
rably in  these  cases,  but  is  wholly  inappli- 
cable except  in  just  such  cases  as  the  one 
above  described.  I  have  often  performed 
the  operation  in  this  way,  and  my 
colleague.  Dr.  Emmet,  has  repeated  it  more  frequently 
than  I  have ;  for  the  relief  it  affords  is  a  great  tempta- 
tion to  its  performance. 

In  operating  for  dysmenorrhoea,  we  must  not  lose 
sight  of  doing  it  in  such  a  way  as  to  favour  the  chances 
of  conception.     How  often  do   we  hear  even   medical 


Fig.  62. 


OF   MENSTRUATION. 


169 


men  say,  "  If  she  could  only  have  a  child  it  would  cure 
her."     To  this  I  always  feel  inclined  to  reply,  "If  we 


Fig.  63. 


could  only  cure  her,  she  would  have  a  child."  We 
should  rememl)er  that  the  physical  causes  that  obstruct 
the  easy  egress  of  the  catamenia,  likewise  obstruct  the 
easy  ingress  of  the  spermatozoa ;  and  to  remove  the  one 
is  in  some  degree  to  relieve  the  other.  If  an  inflamed, 
tursrid  cervical  mucous  membrane  is  a  mechanical  bar- 
rier  to  the  passage  from  one  direction,  it  is  equally  so 
to  it  from  the  other.  If  a  contracted  os  shuts  the  door 
to  an  outlet,  it  closes  it  equally  to  an  inlet.  If  a  cervi- 
cal canal,  flexed  to  such  a  degree  as  to  bring  its  oppo- 
site walls  into  close  contact,  will  produce  the  pain  of 
dysmenorrhoea,  it  will  as  certainly  prevent  the  pain  of 
])arturition,  but  only  by  preventing  conception.  Thus, 
to  treat  dysmenorrhoea  successfully,  is  to  treat  many,  but 
by  no  means  all,  cases  of  sterility  successfully.  Those 
who  have  adopted  the  operation  of  enlarging  the  canal 
of  the  cervix  for  the  cure  of  dysmenorrhoea,  seem  satis- 


lYO  UTERINE  SURaERT. 

fied  to  rest  upon  it  alone  for  the  relief  of  sterility.     But 
more  remains  to  be  done. 

It  would  seem  that  I  have  already  said  enough  on 
the  subject  of  dysmenorrhoea,  and  the  operations  for  its 
relief;  but  as  my  views  previously  published*  have 
been  controverted  by  some  of  the  most  eminent  medical 
men  in  England,  I  shall  say  a  few  words  more. 

Dr.  Henry  Bennetf  objects  to  the  oj^eration  of  in- 
cising the  cervix,  because  he  thinks  he  can  accomplish 
the  same  result  by  sponge  tents ;  and  Dr.  Gream,J 
because  he  thinks  the  bougie  system,  as  introduced  and 
practised  by  M'Intosh,  answers  every  purpose.  Dr. 
Gream  says  he  has  seen  a  case  in  which  the  neck  of  the 
womb  was  so  largely  opened  that  he  could  easily  pass 
his  finger  through  it,  and  touch  the  membranes  of  the 
ovum,  at  the  third  month  of  gestation.  His  patient 
aborted  soon  after ;  and  he  thinks  the  abortion  was  not 
the  result  of  passing  the  finger  into  the  cavity  of  the 
uterus,  but  of  the  inability  of  the  organ  to  retain  its 
contents,  in  consequence  of  the  extensive  division  of  the 
circular  fibres  of  the  cervix. 

This  is,  I  admit,  a  very  rational  inference ;  at  all 
events  we  must  accept  the  fact,  and  inquire  into  its 
cause.  Mr.  Spencer  Wells  §  advocates  the  operation, 
but  says  he  has  seen  several  cases  in  which  the  cervix 
was  too  largely  incised,  and  the  lips  of  the  os  tincse  were 
in  consequence  everted,  rolled  back,  and  almost  lost  in 
the  insertion  of  the  vagina.  This  is  certainly  a  very 
grave  objection  to  the  operation  of  bilateral  incision. 
But  I  have  never  seen  this  accident  after  the  operation, 


*  Lancet,  March  4th  and  11th,  April  1st,  and  June  3rd,  1865. 
t  Lancet,  June  24th,  1865.  %  Lancet,  April  8th,  1865. 

§  Lancet,  May  27th,  1865. 


OP  MENSTRUATION.  l^^ j^ 

as  performed  by  ray  method,  and,  as  before  stated,  Dr. 
Emmet  and  myself  have  done  it  several  hundred  times. 

Let  ns,  then,  inquire  why  it  occasionally  follows  this 
operation  in  the  hands  of  English  surgeons  and  not  in 
ours.  At  first  I  was  disposed  to  believe  that  the  gen- 
tlemen alluded  to  above  had  encountered  unique  and 
isolated  cases ;  but  upon  inquiry  I  am  now  convinced 
that  this  accident  does  occasionally  follow  the  use  of 
the  metro-tome  cache.  It  is  well  to  know  this  fact,  so 
as  to  guard  against  its  occurrence. 

A  short  time  asfo,  a  friend  invited  me  to  see  a  case  of 
fibroid  of  the  uterus,  attended  by  severe  hssmorrhages, 
in  which'  he  had  divided  the  cervix  after  the  plan  of 
Mr.  Baker  Brown.  The  operation  had  been  done  by 
some  one  before,  but  the  bleedings  continued,  and  my 
friend,  desirous  of  giving  the  operation  a  fair  chance, 
determined  to  make  a  more  thorough  division  of  the 
cervix,  for  which  purpose  he  set  the  blades  of  the  metro- 
tome cache  very  widely,  so  as  to  cut  deeply.  The  con- 
sequence was  a  complete  division  of  the  cervix  through 
the  whole  of  the  circular  fibi-es,  from  the  os  tincse  quite 
to  the  cavity  of  the  uterus,  which  produced  the  defor- 
mity that  Mr.  Spencer  Wells  speaks  of.  After  seeing 
this  case,  I  could  no  longer  doubt.  Why  does  this 
accident  happen  after  the  metro-tome  cache  method  of 
operating,  and  not  after  my  plan  ?  The  reason  is 
obvious  enough,  if  we  consider  the  diffei'ence  in  the 
two  methods  of  operating.  To  illustrate  this,  let  the 
diagram  (fig.  64)  represent  the  natural  size  of  the  uterus. 
This  outline  is  taken  from  J)r.  Savage's*  picture  of  a 
dissection  of  a  uterus   of  natural  size.     I  have   made 

*  "  Illustrations  of  the  Surgery  of  the  Female  Pelvic  Organs."  By 
Henry  Savage,  Itl.D.,  Physician  to  the  Samaritan  Hospital  for  Women, 
Plate  8,  fig.  3. 


172 


UTERINE    SURaERT. 


tlie  cervix  project  a  little  more  into  the  vagina,  as  we 


Fig.  64. 

usually  find  it  so   in  the   majority  of  cases   requiring 
operation. 

According  to  my  plan  of  operating,  the  dotted  line 
a  h  would  represent  the  proportion  of  cervical  tissue 
divided  by  the  scissors  (page  156),  while  the  dotted 
lines  a  c^h  c  would  represent  the  extent  of  the  incisions 
made  by  the  blunt-pointed  knife  (fig.  55,  page  157)  up 
towards  the  cavity  of  the  uterus.  Now,  upon  this  same 
diagram,  let  us  see  what  would  be  the  nature  and  extent 
of  the  incisions  made  by  the  metrotome  cache.  We 
will  take  Dr.  Greenhalgh's  instrument,  as  now  made  in 
London  by  Weiss,  and  in  Paris  by  Charriere,  as  being 
the  safest  and  best  of  its  class.  Lay  it  down  upon  this 
diagram,  with  the  point  at  the  fundus  J,  and  the  shoul- 


OP  MENSTRUATION.  17Q 

der  at  the  os  tiucse,  hold  it  firmly  as  we  would  in  ope- 
rating upon  a  patient,  then  draw  the  blades  slowly  down, 
and  the  extent  of  their  movements  will  be  shown  by  the 
dotted  lines  e  d^fd. 

The  twO' methods  differ  theoretically  as  well  as  prac- 
tically. The  one  is  based  upon  the  idea  that  the  obstacle 
to  be  overcome  usually  exists  in  the  lower  portion  of  the 
cervical  canal ;  the  other  upon  the  belief  that  it  is  always 
found  at  the  os  internum.  Now,  by  comparing  the  in- 
cisions made  by  these  two  methods,  it  will  be  seen  that 
the  metro-tome  cache  divides  the  circular  fibres  of  the 
cervix  to  a  greater  extent  at  the  os  internum,  and  through- 
out the  entire  cervix,  than  is  done  by  my  method. 

As  before  said,  too  large  a  division  of  the  cervix  is 
sometimes  followed  by  eversion  and  rolling  back  of  the 
two  lips  of  the  os  tin<:8B.  But  why  only  sometimes  ? 
Large  and  small  are  always  relative  terms.  What  may  be 
small  in  one  case  may  be  comparatively  large  in  another. 
The  metro-tome  cache  cuts  so  much  whether  the  cervix 
be  large  or  small.  We  know  very  well  that  the  size  of 
the  cervix  varies  greatly  in  the  unimpregnated  uterus, 
and  that  in  the  class  of  cases  requiring  this  operation,  it 
is  sometimes  less  than  an  inch  in  diameter.  Now,  if  we 
use  an  instrument  that  cuts  more  than  this,  it  must  of 
necessity  cut  through  the  cervix  from  side  to  side ;  and 
hence  the  danger  of  the  accidents  that  are  said  to  some- 
times follow  this  operation. 

I  have  seen,  in  several  shops,  metro-tomes  that  could 
be  opened  from  one  and  a  half  to  two  inches.  I  am  not 
going  out  of  the  way  to  caution  my  younger  brethren 
against  machines  of  this  sort,  when  I  call  to  mind  the 
fact  that  a  friend  of  mine  recently  used  one  of  them,  and 
was  afterwards  glad  to  see  his  patient  ultimately  recover 
from  the  serious  consequences  of   his  rashness.     If  we 


J^Y4  UTERIXE  SURGERY. 

must  use  a  metro-tome  cache,  let  us  take  Dr.  Green- 
halgh's,  with  its  maximum  expansion,  as  shown  in  the 
diagram  above. 

But  why  do  the  lips  of  the  os  tineas  roll  back  when 
the  cervix  is  too  extensively  incised  ?  The  rationale  is 
this :  The  longitudinal  fibres  of  the  uterus  run  down 
from  the  fundus  to  be  inserted  or  incorporated  antero- 
posteriorly  with  the  circular  fibres  of  the  cervix.  These 
two  sets  of  muscular  fibres  are  antagonistic  in  their  action 
physiologically.  In  a  normal  labour,  the  contraction  of 
the  longitudinal  fibres  of  the  body  must  be  accompanied 
or  followed  by  a  relaxation  of  the  circular  fibres  of  the 
cervix,  or  the  labour  could  not  be  finished.  They  are  as 
antagonistic  as  are  the  flexors  and  extensors  of  the  hand. 
Destroy  the  power  of  the  one  set  of  muscles,  and  the 
other  will  inevitably  take  on  a  tonic  contraction,  and 
draw  the  hand  in  the  direction  of  the  line  of  their  action. 
In  the  operation  of  dividing  the  circular  fibres  of  the 
cervix  uteri  by  the  metro-tome  cache,  if  the  whole  dia- 
meter of  the  cervix  be  cut  entirely  through,  we  must  of 
necessity  cut  the  whole  of  its  circular  muscular  fibres, 
which  destroys  their  contractility,  and  removes  the  force 
that  bound,  as  it  were,  in  a  bundle  the  terminal  extre- 
mities of  the  longitudinal  fibres,  which  then  take  on  a 
tonic  rigidity,  retracting  the  divided  lips  of  the  os  tincse, 
and  producing  the  deformity  that,  we  must  admit,  is 
occasionally  seen  to  follow  the  metro-tome  cache  method 
of  operating. 

Whether  my  explanation  be  correct  or  not,  does  not 
in  the  least  affect  the  fact  under  consideration ;  and  the 
young  surgeon  cannot  be  too  careful,  for  if  he  should 
unfortunately  cut  too  much,  there  is  no  remedy  for  his 
mistake.  It  is  far  better  to  cut  too  little,  even  at  the 
risk  of  being  compelled  to  repeat  the  operation. 


SECTION  III. 


THE  OS  AND  CERYIX  UTERI  SHOULD  BE  SUFFI- 
CIENTLY OPEN,  NOT  ONLY  TO  PERMIT  THE 
FREE  EXIT  OF  THE  MENSTRUAL  FLOW,  BUT 
ALSO  TO  ADMIT  THE  INGRESS  OF  THE  SPERMA> 
TOZOA. 


'       SECTION    III. 

THE  OS  AND  CERVIX  UTERI  SHOULD  BE  SUFFICIENTLY  OPEN, 
NOT  ONLY  TO  PERMIT  THE  FREE  EXIT  OF  THE  MEN- 
STRUAL FLOW,  BUT  ALSO  TO  ADMIT  THE  INGRESS  OF  THE 
SPER  lATOZOA. 

In  the  preceding  pages  we  have  followed  symptomatology 
to  the  detection  and  treatment  of  organic  disease,  but 
now  we  propose  to  ask  in  what  particular  organic  struc- 
ture varies  from  a  normal  condition,  irrespective  of 
rational  signs  ?  It  will  then  be  necessary  to  inquire  into 
the  normal  conditions  and  relations  of  the  uterus,  before 
speaking  of  its  anomalies,  and  their  influence  on  concep- 
tion. 

Anatomists  tell  us  that  the  uterus  is  pear-shaped, 
and  flattened  a  little  antero-posteriorly  ;  that  it  is  from 
two  and  a  half  to  three  inches  long ;  an  inch  and  a  half 
wide,  more  or  less,  at  its  largest  part ;  and  about  an  inch 
thick  ;  that  it  is  divided  into  fundus,  body,  and  cervix  ; 
that  its  cavity  is  from  two  and  a  quarter  to  two  and  a 
half  inches  lon^:,  the  canal  of  the  cervix  beinoj  a  little 
longer  than  that  of  the  body  ;  that  the  os  tincse  is 
generally  round  in  the  nulliparous  uterus ;  elliptical  and 
transverse  after  child-bearing  ;  and  that  the  cervix  is 
rounded  and  embraced  by  the  vagina,  which  is  inserted 
higher  behind  than  before,  thus  making  the  posterior 
intravaginal  portion  of  the  cervix  a  little  longer  than 
the  anterior.  But  anatomists  do  not  tell  us  how  far  the 
intravaginal  portion  of  the  cervix  should  project  into  the 


j[78  UTERINE    SURaERY. 

vagina,  or  what  proportion  it  should  bear  to  the  supra- 
vaginal section,  which,  by  the  bye,  is  an  important 
matter  to  determine.  Not  havincr  time  or  inclination  to 
go  to  the  dead-house  for  the  verification  of  this  point,  I 
shall  describe  the  neck  of  the  womb  as  I  see  it  in  daily 
investigations  on  the  living.  I  assume  that  a  normal  os 
tincse,  whether  round  or  transverse  and  elliptical,  should 
be  open,  and  filled  with  a  slippery  translucent  mucus  of 
slightly  alkaline  reaction  ;  that  the  cervix  should  be 
rounded,  truncated,  and  elastic  to  the  touch ;  that  the 
intravaginal  portion  should  be  about  a  fifth  or  not  more 
than  a  fourth  of  its  whole  length,  i.e.^  from  a  quarter  to  a 
third  of  an  inch  anteriorly,  and  a  fraction  more  poste- 
riorly ;  that  the  canal  of  the  cervix  should  be  straight 
or  curved  slightly  forward  ;  and  that  the  axis  of  the 
whole  organ  should  stand  at  about  i-ight  angles  with 
that  of  the  vagina,  being  neither  anteverted  nor  retro- 
verted  to  any  great  degi-ee.  Any  woman  with  such  a 
state  of  the  uterus  will  always  conceive  in  three  or  four 
months  after  marriage,  if  everything  else  is  right. 

Having  laid  down  this  ideal  of  what  the  womb 
should  be,  an  ideal  that  has  not  been  imagined,  but 
drawn  from  actual  observation  in  the  clinique  and  the 
consulting-room,  we  shall  proceed  to  the  examination  of 
the  sterile,  unimpregnated  uterus,  to  see  where  and  how 
it  may  differ  from  a  normal  conceptive  state.  This  neces- 
sarily embraces  anomalies  or  deviations  from  a  normal 
state  ;  1st,  of  the  mouth  of  the  womb  ;  2nd,  of  the 
cervix  ;  and  3rd,  of  the  body  :  and  this  brings  us  at 
once  to  the  third  general  subdivision  of  our  subject,  viz., 
that  the  os  and  cervix  uteri  should  be  sufliciently  open 
not  only  to  permit  the  free  discharge  of  the  menstrual 
flow,  but  also  to  admit  the  ingress  of  the  spermatozoa. 

It  might  appear,  at  the  first  glance,  that  this  propo- 


OS  TINC^- ABNORMAL.  Jf^g 

siticn  had  been  embraced,  and  efficiently  discussed,  in 
the  preceding  article  on  painful  menstruation.  But 
experience  teaches  us  differently  ;  for  instance,  how  often 
do  we  see  sterility  where  there  is  no  symptom  of  disease 
so  far  as  physical  suffering  is  concerned  ?  Menstruation 
may  be  perfectly  normal,  there  may  be  no  back-ache, 
no  vesical  tenesmus,  no  bearing-down,  no  leucorrhoea, 
indeed,  no  sign  of  diseased  action ;  and  when  we  come 
to  a  physical  exploration,  we  may  even  find  the  uterus 
of  proper  size,  in  a  normal  position,  and  with  a  straight 
cervical  canal,  but  the  os  may  not  be  laiger  than  a  pin's 
head,  and  if  to  this  be  added  induration  of  the  cervix, 
the  case  is  almost  necessarily  sterile  ;  for  while  the  os 
and  cervix  are  capacious  enough  to  transmit  the  outward 
flow,  the  OS  itself  is  not  capable  of  admitting  the  sperm, 
and  without  this  there  can,  of  course,  be  no  conception. 
This  is  not  theoretical,  and  I  might  give  numerous  illus- 
trations in  proof,  but  one  will  suffice. 

Mrs.  X.,  of  fine  form  and  vigorous  health,  had  been 
married  many  years  (thirteen  or  fourteen)  without 
offspring.  Menstruation  regular,  normal:  never  had 
leucorrhoea,  or  any  other  symptom  of  uterine  disease ; 
and  people  wondered  why  such  a  fine  specimen  of 
womankind  should  not  become  a  mother;  and  they 
very  generally  and  erroneously  inferred  that  it  could 
not  be  the  fault  of  such  a  physical  organization.  She 
consulted  many  eminent  medical  men,  and  took  baths 
and  mineral  waters,  and  cordials,  elixirs,  and  nostrums 
without  number.  She  had  submitted  to  be  bougied  till 
an  attack  of  pelvic  cellulitis  supervening  had  well-nigh 
cost  her  her  life.  Indeed,  I  never  saw  any  woman  so 
determined  on  having  offspring,  and  for  that  purpose 
she  was  readj''  to  suffer  anything  and  to  take  any  reason- 
able risk.     On  examination,  I  found  the  uterus  in  proper 


180 


UTERINE   SURGERY. 


position,  and  rather  under  size  ;  but  as  menstruation  was 
perfectly  normal,  the  size  of  the  organ  was  not  deemed 
of  any  great  importance.  The  canal  was  straight,  but 
the  OS  was  exceedingly  small,  and  the  cervix  felt  to 
the  touch  like  a  little  round  marble,  and  almost  as  hard. 
Of  course  there  was  but  one  thing  to  be  done,  viz., 
to  open  the  os  and  cervix  by  the  bilateral  operation. 
This  lady,  who  had  already  suffered  so  much  from  dilata- 
tion, thought  the  operation  a  small  affair  compared  to 
the  result  hoped  for. 

In  this  case,  I  was  able  to  say  beforehand  that  she 
would  almost  certainly  conceive  after  the  operation. 
Very  often  we  can  say  to  one,  "Yes,  you  are  almost 

sure  to  conceive ;"  while  to 
another  we  are  compelled  to 
say,  "  Conception  is  probable  ;" 
to  another,  "It  is  possible;" 
and  to  others,  "  It  is  impos- 
sible." 

This  diagram  (fig.  65)  re- 
presents the  relative  condition 
of  the  OS  and  cervix.  The  ope- 
ration was  done  in  April,  and 
conception  occurred  in  Decem- 
ber following.  Here  there  was 
no  dysmenorrhoea,  as  already 
remai'ked.  And  why  ?  Simply 
because  there  was  no  mechanical  obstruction  to  tlie  flow. 
The  canal  of  the  cervix  was  small,  but  straight ;  and  its 
mucous  membrane  was  not  cono^ested.  Had  it  been  a 
little  crooked,  there  would  probably  have  been  pain,  for 
it  was  very  small.  But  as  small  as  the  os  was,  it  per- 
mitted the  easy  exit  of  the  menstrual  flow,  while  it 
prevented  the  ingress  of  the  sperm.     This  is  proved  by 


Fig.  65. 


OS   TINC^— ABNORMAL. 


181 


the  fact  that  she  was  sterile  for  thirteen  or  fourteen 
years,  during  which  time  she  tried  all  sorts  of  remedies 
to  overcome  it,  and  then  became  pregnant  in  a  few 
months  after  the  performance  of  the  operation. 

I  have  seen  many  other  similar  cases,  and  a  great 
many  like  it  artificially  produced  by  the  injudicious  use  of 
potassa  fusa,  potassa  c.  calce,  and  even  nitrate  of  silver. 

Sometimes  the  os  tincse  becomes  wholly  occluded  by 
the  prolonged  use  of  these  agents ;  more  frequently  it  is 
partially  closed,  and  the  cervix  always  feels  indurated. 
Whether  the  induration  is  due  to  the  action  of  the  reme- 
dy, or  to  the  inflammation  that  called  for  its  applica- 
tion, I  shall  not  pretend  to  say  ;  but  I  have  generally 
found  artificial  occlusion  of  the  os  to  co-exist  with  indu- 
ration of  the  cervix.  This  produces  a  state  of  acquired 
sterility.  I  have  met  with  it  more  frequently  amongst 
those  who  had  once  borne  chihlren,  thouo^h  I  have  seen 
it  in  those  who  had  not.  A  marked  example  of  this 
was  found  in  the  out-door  practice  of  the  Woman's  Hos- 
pital, in  a  young  unmarried  woman  who  had  had  potassa 
c.  calce  applied  some  months  before  at  one  of  our  dis- 
pensaries. When  the  finger  was  introduced  into  the 
vagina,  the  cervix  was  found 

in    proper    position,  but   it         \  i/ 

was  perfectly  round  and  hard,  \|p^'^-^_.,^  "'^'W^V 

and    no   os   was  to  be    felt.        /^P^'  '  '"-i/  \ 

When    the     speculum    was      /ff    ,g||,„,^     J     I 
used,  we  found  the  os  com-  *        '^    '{'J,(,    I 

pletely  bridged    over  by    a  ""^    ^  .„■*'-'  |        || 

dense  fibrous  band  of  union       ,  t,  ,     - ,        mnV   ■     \ 

with    a    little    opening     at     \?^'>*:«'^^" '  ''^^#f'''        1 

each  extremity,  which  would  pj^  gg 

not  admit  an  ordinary- sized 

probe.    Fig.  66  represents  the  appearance  of  tlie  os  in 


182 


UTERINE  SURGERY. 


this  case,  and  shows  the  two  little  points  a  a^  whence 
issued  the  menstrual  flow. 

I  saw,  in  consultation  with  Sir  Joseph  Olliffe  in  Paris, 
in  1863,  a  lady  in  the  higher  ranks  of  life,  who  had 
been  twice  married  without  offspring,  and  whose  os 
tincse  had  been  thus  artificially  agglutinated  by  the  pro- 
longed use  of  the  nitrate  of  silver  during  her  first  marriage. 

When  this  mechanical  obstruction  to  the  egress  of 
the  menses  is  thus  artificially  produced,  we  may  find 
more  or  less  sufl:ering  and  general  malaise  attending  the 
flow,  which  becomes  unusually  prolonged,  always  very 
dark-coloured,  often  of  tarry  consistence,  and  sometimes 
offensive.  The  cessation  of  the  flow  is  then  followed  by 
a  dark-brownish  fine  coffee-grounds-like  mucus,  which 
continues  for  a  few  days,  and  frequently  irritates  the 
parts  with  M^hich  it  comes  in  contact.  The  mechanical 
obstruction  at  the  os  pi-e venting  the  easy  outlet  of  the 
flow,  causes  a  partial  retention  of  the  secretions,  which 
thereby  undergo  some  change,  that  reacts  upon  the  tis- 
sues, and  produces  a  sort  of  subacute  endo-metritis.  Of 
course  the  only  remedy  is  the  restoration  of  the  os  and 
cervix  to  a  normal  state,  by  cutting  the  canal  open,  and 
keeping  it  so. 

This  species  of  artificial  occlusion  of  the  os  by  caustic 
applications  is  not,  I  am  glad  to  say,  very  common,  but 
I  fear  it  occurs  more  frequently  than  it  should.  FortU' 
nately  its  effects  are  easily  remedied  if  they  are  recog- 
nized. 

The  cases  of  it  that  have  fallen  under  my  observation 
did  not  present  themselves  on  account  of  the  sterility 
that  it  engendered,  but  because  of  the  ordinary  symp- 
toms of  uterine  disease  from  which  they  suffered.  Several 
of  these,  when  cured  of  the  organic  diflSculty,  were 
rendered  fruitful  again. 


OS  TINO^— ABNORMAL.  ]^g3 

1  have  repeatedly  said  that  the  subjects  of  sterility 
are  naturally  arranged  in  two  great  classes ;  viz.,  those 
who  have  never  "borne  children,  and  those  who,  having 
once  conceived,  cease,  from  some  cause  or  other,  to  con- 
ceive again. 

Very  perfect  illustrations  of  this  last  class  may  be 
found  in  those  who  have  had  the  os  uteri  artificially 
sealed  up  by  the  injudicious  use  of  the  potassa  fusa  or 
potassa  c.  calce.  Amongst  the  cases  of  this  sort  that  I 
have  seen,  I  now  call  to  mind  two  ladies,  who  had  been 
treated  by  the  same  physician. 

They  are  important  enough  in  their  bearings  on  this 
subdivision  of  our  subject,  to  give  a  few  particulars. 
A  lady,  aged  thirty  years,  married  at  twenty-one,  had 
two  children,  the  youngest  six  years  old.  There  was 
nothing  peculiar  about  the  labours,  but  she  was  subject 
to  leucorrhcea  after  the  last  one,  for  which  she  had  orene- 
ral  constitutional  treatment,  and,  after  a  while,  local 
applications  of  the  potassa  c.  calce,  nit.  arg.,  &c.  Menses 
rather  profuse  but  otherwise  normal,  till  about  two 
years  ago,  they  became  gradually  very  tedious  and  pro- 
longed, lasting  nine  or  ten  days,  instead  of  three  or  four, 
as  they  did  previously  to  the  potassa  c.  calce  treatment. 
The  flow  was  now  scanty,  very  dark-coloured,  almost 
black,  attended  with  nausea,  nervous  irritability,  and  a 
sense  of  utter  prostration,  together  with  bearing-down, 
weight  and  soreness  in  the  rectum,  and  neuralgic  pains 
at  the  end  of  the  coccyx.  She  also  had  great  tender- 
ness and  sensitiveness  at  the  mouth  of  the  vaccina.  The 
fundus  was  considerabh^  hypertrophied,  the  cervix  was 
also  hypertrophied  and  indurated,  and  felt  more  like  a 
small  globe  pessary  than  anything  else  ;  and  it  was 
utterly  impossible  to  detect  the  os  tincae  by  the 
touch. 


184 


UTERINE  SURGERY 


Fig.  67  shows  about  the  size  and  relation  of  the  little 
opening  through  which  the  menses  made  their  tedious 
escape.  The  canal  was  opened  by  the  bilateral  incision. 
The  whole  cervix  was  of  fibrous  hardness,  and  the  resist- 
ance to  the  knife  was  very  great.  As  usual  in  these 
cases,  there  was  but  little  haemorrhage,  but  there  was 
great  trouble  in  keeping  the  os  open.  However,  it 
remained  sufficientljT^  so.  The  next  menstruation  was 
normal,  and  in  four  months  she  conceived  again,  after 
an  acquired  sterility  of  six  years,  due,  firstly,  to  granular 


Fig.  67. 

engorgement,  and  its  attendant  leucorrhoea,  and  lastly,  to 
the  potassa  c.  calce  treatment  and  its  result,  occlusion 
of  the  OS. 

I  do  not  object  to  the  use  of  potassa  c.  calce  judi- 
ciously applied,  but  it  is  well  for  us  to  know  that  it  is 
ail-powerful  to  do  mischief,  while  we  intend  only  to  do 
good  with  it.  I  feel,  therefore,  justified  in  pressing  this 
matter  a  little  more  on  the  attention  of  the  reader. 

Mrs.  M,,  aged  thirty-six,  three  children,  youngest  six 
years;  some  uterine  trouble  ever  since  the  last  labour; 
was  treated  for  "ulceration"  by  potassa  c.  calce  thi'ee 
years  before  I  saw  her  in  April,  1856.     Her  menses, 


OS  TINC^ -ABNORMAL.  185 

scanty,  dark-coloured,  of  a  tarry  ajDpearance,  were  now 
preceded  by  pain  for  a  week. 

It  is  a  waste  of  time  to  give  general  or  even  local 
symptoms. 

The  uterus  was  anteverted,  the  fundus  hypertrophied, 
the  cervix  almost  as  hard  as  curtilage,  and  the  os  was 
contracted  to  a  little  round  point,  that  could  not  be 
detected  by  the  touch. 

The  OS  was  cut  open;  the  next  menstruation  was 
painless  and  normal,  and  the  enlargement  of  the  fundus 
soon  subsided  as  a  consequence  of  the  easy  exit  of  the 
menses,  and  conception  occurred  a  few  months  after- 
wards. 

But  I  pass  from  this  class  of  cases  to  another,  where 
the  OS  is  open  enough  to  permit  the  easy  exit  of  the 
flow,  but  where  there  may  still  be  a  mechanical  obstruc- 
tion to  the  ingress  of  the  spermatozoa.  It  is  not  suflS.- 
cient  to  say  that  the  mouth  of  the  womb  is  large 
enough,  and  that  it  admits  easily  the  passage  of  a 
bougie  or  a  sound. 

To  illustrate  my  meaning  I  turn  to  my  note-book. 
Mrs.  -— ~,  aged  thirty-five,  two  children,  youngest  ten 
years  old.  She  had  been  in  bad  health  for  a  long  time, 
and  was  treated  by  a  very  eminent  physician,  Dr.  Duane, 
of  Schenectady,  who  sent  her  to  me  in  June,  1856.  The 
uterus  was  anteverted,  and  greatly  hypertrophied,  being 
three  inches  and  three  quarters  to  the  fundus ;  the 
cervix  was  the  seat  of  fibrous  engorgement ;  the  menses 
were  profuse,  lasting  five  or  six  days,  returning  in  seven- 
teen ;  and  she  was  ansemic  and  prostrated. 

A  course  of  treatment,  local  and  constitutional,  was 
agreed  upon,  and  Dr.  Duane  sent  his  patient  to  me 
again  in  the  autumn.  She  was  somewhat  improved  ; 
the  depth  of  the  uterus  was  three  and  a  quarter  inches 


186 


UTERINE    SURGERY. 


instead  of  three  and  three  quarters  ;  and  the  hyper- 
trophy and  induration  of  the  cervix  were  better,  but 
there  was  little  or  no  improvement  otherwise. 

I  was  at  a  loss  what  more  to  do  for  her  relief,  and 
felt  very  sure  that  her  ten  years  of  sterility  was  due 
not  so  much  to  the  state  of  her  general  health  as  to 
the  peculiar  conformation  of  the  mouth  of  the  womb, 
which  certainly  prevented  the  ingress  of  the  sper- 
matozoa. Many  of  us  think  that  a  pregnancy  will  often 
modify  the  nutritive  functions  of  the  uterus  in  such  a 
way  as  to  remove  engorgements,  hypertrophic  condi- 
tions, and  even  small  fibroids.  With  my  mind  full  of 
this  idea,  I  asked  my  patient,  rather  jocularly,  if  she 
would  like  to  have  more  offspring.  She  promptly  re- 
plied, "No."  "Well,"  said  I,  "it's  difficult  for  me  to 
determine  what  else  to  do,  if  you  will  not  consent  for 
me  to  rectify  the  condition  of  the  mouth  of  the  womb, 
so  that  conception  may  take  place."  She  did  not  think 
it  possible,  and  hardly  believed  me  to  be  in  earnest. 

Now   it  may  be    asked 
what  could  be  the  trouble 
with    the    mouth    of    the 
womb,  when  she  had  had 
children,  and  when  she  still 
menstruated     without    the 
least  difficulty.     From  the 
birth  of  the  last  child  she 
had  had  leucorrhoea,    as  a 
consequence     of    granular 
engorgement  of  the  cervix. 
Dr.  Duane  had  cured  this  long  ago,  and  there  still 
remained,  as  previously  stated,  some  hypertrophy  of  the 
cervix.      This,   too,  he  had  removed,  in  a   great  mea- 
sure, during   the    summer,    by    two    small    potassa    c 


Fig.  68. 


OS   TINC^— ABNORMAL.  I^'J 

calce  issues,  one  on  eacli  lip  of  the  os  tincse.  But  tliere 
still  remained  the  same  mechanical  obstruction  at  the 
OS  as  before,  which  is  represented  by  fig.  68.  A  cres- 
centic-shaped  os  is  by  no  means  uncommon.  We 
often  see  'it  in  anteversions,  and  I  have  frequently 
seen  it  where  the  position  of  the  uterus  was  nor- 
mal. We  may  have  it  where  there  has  never 
been  conception,  or  it  may  occur  after  child-bearing, 
as  a  consequence  of  chronic  inflammation  of  the  cervix, 
with  hypertrophy  of  the  cervical  mucous  membrane. 
Here  it  presented  no  barrier  whatever  to  an  outward 
flow ;  but  a  glance  at  the  peculiar  projection  a  from  the 
anterior,  lip,  shows  what  a  perfectly  valvular  closure  it 
opposed  to  any  inward  flow.  Wlien  this  little  tubercle 
a  was  hooked  with  a  small  tenaculum  and  pulled  down- 
wards, so  as  to  open  the  canal  of  the  cervix,  and  pei-mit 
a  view  of  its  cavity,  this  hypertrophic  condition  was 
seen  to  extend  up  along  the  anterior  face  of  the  cervix 
for  an  inch.  The  curvilinear  dotted  line  c  shows  the 
course  of  the  incision  by  which  this  was  removed.  It 
was  a  triangular  wedge,  as  seen  in  fig.  69, 
the  apex  having  reached  nearly  to  the  os  in- 
ternum. There  was  but  little  bleeding,  and 
this  was  controlled  at  once  by  the  pressure  of 
a  sponge  probang,  and  then  by  the  applica- 
tion of  a  pledget  of  cotton,  wet  with  a  solu- 
tion of  the  perchloride  of  iron.  Fig.  go. 

The  wound  was  healed  by  the  time  of  the 
next  menstruation ;  and  my  patient  went  home  with 
the  OS  presenting  a  perfectly  normal  appearance.  Not- 
withstaudino-  her  feeble  state  of  health,  and  the  lenofth 
of  time  since  the  birth  of  her  last  child,  conception 
occurred  a  month  after  the  operation.  Slie  went  the  full 
time,  and  was  safely  delivered  by  Dr.  Duane  of  a  fine 


188 


UTERINE   SURGERY. 


boy.  But  I  am  constrained  to  say  that  tlie  pregnancy 
produced  no  good  effect  either  constitutionally  or  locally. 
I  had  occasion  to  examine  the  uterus  some  four  or  five 
months  after  delivery,  and  its  condition  was  about  the 
same  as  at  the  time  of  conception.  The  case  is  valuable 
only  as  illustrating  one  of  the  mechanical  obstacles  to 
conception.  It  is  not  exceptional,  for  I  have  seen  other 
similar  cases. 

Again,  the  mouth  of  the  womb  may  be  open  enough 
to  let  the  menses  flow  out  freely,  and  it  may  be  even 
large  enough  to  admit  easily  a  No.  8  or  10  bougie,  and 
yet  be  absolutely  closed  to  the  ingress  of  the  sperma- 
tozoa ;  and  that  without  any  excrescence  or  malforma- 
tion. This  condition  is  a  very  common  cause  of  acquired 
sterility,  and  occurs  in  this  way :  Labour  is  followed  by 
a  chronic  inflammation  of  the  cervix,  which  becomes 
hypertrophied ;  the  inflammation  or  granular  erosion  is 
cured,  but  the  hypertrophic  condition  conjoined  with 
indui'ation  remains,  and  the  two  indurated,  thickened 
lips  of  the  OS  tincae  lie  in  close  apposition,  yielding 
readily  to  any  fluid  passing  down,  but  opposing  any 
passing  up  the  canal.  We  too  often  overlook  this  cause 
of  sterility,  common  as  it  is.     We   are  apt  to  say  the 

mouth  of  the  womb  is  all 
right,  because  it  admits  a 
large  bougie,  and  gives  free 
vent  from  the  uterine  cavity. 
Now,  what  is  to  be  done 


with  such  a  case  ?  The  os 
is  a  straight  transverse  line, 
with  the  two  opposite  bor- 
ders crowded  obstinately 
against  each  other  (fig.  70). 
It  is  long  enough  from  side  to  side,  but  autero-posteri- 


FiO.  *io. 


OS  TINC^— ABNORMAL.  JgQ 

orly  it  has  lost  its  gaping,  graceful  oval  form,  and 
althougli  quite  as  large  as  it  ought  to  be,  it  is  still  to  all 
intents  and  purposes  practically  closed.  Such  an  os  as 
this  may  be  bougied  till  both  surgeon  and  patient  are 
mutually  tired  out,  without  any  result  whatever ;  and 
there  is  but  one  thing  to  do,  viz.,  to  incise  the  cervix  as 
for  dysmenorrhoea.  It  may  seem  paradoxical  to  enlarge 
an  OS  that  is  already  large  enough,  but  the  only  way  in 
which  I  have  ever  succeeded  in  causing  a  permanent 
receding  of  such  compressed  lips,  is  by  a  bilateral  divi- 
sion of  the  circular  fibres  of  the  indurated  cervix. 

In  March,  1859,  a  lady,  twenty-seven  years  old,  con- 
sulted me  on  account  of  acquired  sterility.  iShe  had  had 
one  child  five  years  before, — no  conce]>tion  since.  As 
she  and  her  husband  were  both  in  vigorous  health,  she 
wished  to  know  the  cause  of  what  was  to  them  a  source 
of  great  unhappiness.  She  had  been  told  by  her  family 
physician  that  there  was  no  reason  why  she  should  not 
conceive.  On  the  contrary,  I  said  that  conception  was 
utterly  impossible,  with  the  mouth  of  the  womb  as  it 
was,  and  explained  the  necessity  of  a  surgical  operation. 
Being  satisfied  of  its  painlessness  and  its  safety,  she  sub- 
mitted to  it  at  once.  The  cervix  was  hard  and  gristly, 
but  the  incisions  produced  the  desired  result  of  giving 
the  OS  an  elliptical  shape. 

It  required  nice  care  to  prevent  a  contraction  of  the 
OS  to  its  former  condition.  Fortunately  all  went  on 
well,  and  in  less  than  twelve  months  from  the  date  of 
the  operation  the  mother  was  safely  delivered  of  twins, 
which,  she  said,  made  up  amply  for  her  lost  time. 

In  fifteen  months  after  this  she  gave  birth  to  another 
child,  wliich  proved  that  the  mouth  of  the  womb  re- 
mained properly  open. 

I  might  go  on  to  enumerate  various  other  changes 


j[90  UTERINE  SURGERY. 

that  take  place  in  the  appearance  and  form  of  the  os^ 
as  a  result  of  accident,  inflammation,  engorgement,  or 
hypertrophy,  any  and  all  of  which  may  in  some  sort  in 
terfere  with  the  passage  of  the  spermatozoa  to  the  cavity 
of  the  uterus.  Many  of  these  we  will  recognize  and 
remedy,  while  great  numbers,  even  when  fully  under- 
stood, will  baffle  our  efforts. 

We  all  know  that  a  protracted  labour  with  impacted 
head  often  produces  sloughings  of  the  vagina,  which 
result  in  fistulous  openings  into  the  bladder  or  rectum  ; 
but  sometimes  we  have  the  impaction  in  the  superior 
strait  before  the  head  has  passed  through  the  cervix,  and 
then  we  may  have  a  sloughing  of  some  part  of  the  cervix 
without  necessarily  a  fistulous  communication  with  the 
bladder  or  rectum.  Sometimes  we  see  the  anterior  lip 
destroyed ;  again  the  lateral  portion  of  the  cervix  ;  again 
the  posterior  lip ;  and  a  few  years  ago,  Professor  Isaac 
E.  Taylor,  of  the  Bellevue  Hospital  Medical  College, 
showed  me  the  entire  cervix  that  had  been  thrown  off 
by  slough,  in  consequence  of  impaction.  In  almost  all 
the  cases,  the  cicatrizing  process  produces  malforma- 
tions of  the  OS  that  mechanically  prevent  conception. 
I  might  give  an  immense  number  of  illustrations  of  these 
unfortunate  cases,  drawn  from  the  records  of  the  Wo- 
man's Hospital,  but  one  will  suffice. 

Fig.  71  represents  the  appearance  of  a  case  that  was 
in  the  Woman's  Hospital  in  1856  ;  the  anteilor  lip  of  the 
OS  tincse  was  entirely  destroyed,  but  the  posterior  being 
intact,  projected  slightly  forwards,  so  as  to  hide  the 
small  opening  leading  to  the  canal  of  the  cervix.  There 
was  a  minute  vesico- vaginal  fistula  which  was  easily 
cured,  but  the  mouth  of  the  womb  remained  contracted, 
puckered,  and  over-lapped  by  the  posterior  lip  in  such  a 


OS  TINCJE— ABNORMAL.  J  9]^ 

way  as   to  form    a  complete   barrier  to    a   subsequent 
conception. 

Professor  Forclyce  Barker,  of  the  Bellevue  Hospital 
Medical  College,  sent  me  a  case  in  1858,  in  which  the 
whole  cervix  had  sloughed  off  without  injury  to  the 


Fig.  71. 


vagina ;  and  the  cicatrizing  process  had  here  produced 
a  complete  obliteration  of  the  os.  When  the  finger  was 
passed  into  the  vagina,  we  could  feel  the  womb  as  if  it 
were  sitting  on  this  canal,  seemingly  attached  to  it  by  a 
narrow  neck,  but  not  projecting  into  it  at  all.  Here, 
not  only  the  os  but  the  canal  of  the  cervix  was  oblite- 
rated. It  was  no  easy  matter  to  make  an  opening 
through  this  dense  isthmus  of  fibrous  tissue  up  to  the 
cavity  of  the  organ.  But  I  fortunately  succeeded,  and 
kept  the  canal  open  with  an  intra-uterine  stem  for  two 
months,  tyid  the  patient  left  the  Hospital ;  l)ut  she 
returned  in  two  or  three  months  afterwards,  just  as  she 
was  when  I  first  saw  her.  The  operation  was  repeated 
a  second  and  even  a  third  time,  and  the  canal  was 
eventually  obliterated  a  second  and  a  third  time. 

But  other  deformities  of  the  os  tineas  may  occur  of  a 
less  formi,  table  character,  still  resulting  in  complete 
■sterility.       As   so    often    said,    any    organic    condition 


192 


UTERINE   SURGERY. 


whatever  that  tends  to  prevent  the  passage  of  the 
spermatozoa,  necessarily  prevents  conception.  Wishing 
to  impress  this  point  on  the  young  surgeon,  I  shall 
continue  clinical  illustrations  of  my  meaning. 

A  lady,  aged  twenty-six  years,  had  had  two  labours 
at  full  term,  the  last  six  years  ago.  This  labour  was 
violent  and  very  rapid,  lasting  only  half  an  hour.  The 
child  was  large,  and  the  head  was  probably  forced 
through  the  neck  of  the  womb  before  it  was  sufficiently 
dilated,  and  the  os  was,  consequently,  lacerated  from 
side  to  side.  This  healed  slowly,  but  she  i*emained 
sterile  afterwards. 

Fig.  72  represents  the  appearance  of  the  os :  the 
anterior  half  of  the  cervix  was  twice  as  thick  as  the 
posterior,  while  the  posterior  lip  of  the  os  over-lapped 
the  anterior,  closing  it  valvularly  and  perfectly.     The 

cervix  was  indurated,  and  the 
cicatrices  resultins:  from  the 
la.-eration  and  subsequent 
healing  could  be  distinctly 
seen  extending  laterally  fi'om 
the  OS  to  the  insertion  of  the 
vagina.  This  lady  was  anxious 
for  more  offspring ;  and  I 
proposed  to  cut  off  the  poste- 
rior over-lapping  lip  of  the  os, 
as  indicated  by  the  dotted  line 
«,  which  would  sti-aighten  the 
canal  and  open  the  door  to 
the  entrance  of  the  spermatozoa,  that  is,  if  the  healing 
process  could  be  managed  so  as  to  prevent  undue 
contraction.  However,  she  was  frightened  at  the  idea  of 
an  operation,  and  would  have  nothing  done. 

But  it  may  be  said,  "Your  views  of  conception  are 


Fig,  72. 


OS  TINC^— ABNORMAL. 


193 


entirely  too  mechanical."  The  act  of  copulation  is 
purely  mechanical.  It  is  only  necessary  to  get  the 
semen  into  the  proper  place  at  the  proper  time.  It 
makes  no  difference  whether  the  copulative  act  be 
performed  with  great  vigour  and  intense  erethism,  or 
whether  it  be  done  feebly,  quickly,  and  unsatisfactorily ; 
provided  the  semen  be  deposited  at  the  mouth  of  the 
womb,  everything  else  being  as  we  would  have  it.  Thus 
far  I  accept  the  charge  of  mechanical  views. 

To  illustrate  the  principles  of  the  operation  above 
suggested,  here  is  a  case  in  point.  A  widower  in  the 
prime  of  life,  in  good  health,  the  father  of  children, 
married  a  young  wife,  who  at  the  end  of  five  years 
remained  sterile.  The  fault  was  not  with  the  husband, 
as  shown  by  his  previous  marriage.  The  wife's  men- 
struation was  regular,  lasted  two  days,  and  not  painful 
to  any  great  degree,  except 
when  she  was  exposed  to  cold 
durino;  the  advent  of  the  flow. 
She  suffered  slightly  from  con- 
stipation and  haemorrhoids, 
but  her  great  trouble  was 
leucorrhcea,  with  pruritus. 
An  examination  showed  that 
there  was  no  granular  ero- 
sion of  the  OS,  and  that  the 
irritating  secretion  was  a  pure 
utorrhcea. 

Fig.  73  represents  the  an- 
atomical peculiarities  of  the 
OS  and  cervix  and  the  course 
of  the  canal.  The  position  of 
the  uterus  was  normal.  The  intra-vaginal  portion  of 
the   cervix    was    irregularly    developed,    the    anterior 

13 


Fig.  73. 


194  UTERINE  SURGERY. 

segment  being  not  more  than  one-fourth  as  long  as 
the  posterior.  In  other  words,  the  os  tincse  was  fouLcl, 
as  it  were,  on  the  anterior  face  of  the  cervix  instead  of 
being  central,  as  at  a^  in  a  line  with  the  long  axis  of  the 
cervical  canal.  The  os  was  very  small,  but  by  means 
of  a  sponge-tent  it  was  ascertained  that  the  anterior 
face  of  the  cervix  at  c  was  the  seat  of  a  granular 
condition  of  the  cervical  membrane  evidently  giving 
rise  to  the  morbid  secretion  that  irritated  the  external 
parts. 

This  lady  did  not  consult  me  on  account  of  her 
sterility,  but  solely  for  the  relief  of  her  physical  suffer- 
ings. Conception  would  be  absolutely  impossible  in 
such  a  case  as  this.  I  have  seen  many  like  it,  and  they 
are  of  necessity  always  sterile.  Such  malformations  are 
evidently  congenital. 

Three  months  of  treatment  here  produced  no  sort  of 
improvement,  either  of  utorrhoea  or  pruritus.  Sponge- 
tents  and  caustic  to  the  granulations  at  c  combined 
with  a  tonic  invigorating  course  were  wholly  useless. 

The  question  then  arose,  "  What  else  can  surgery  do 
for  her  relief?"  The  only  way  that  I  could  see  to  cure 
the  utorrhoea,  was  to  open  permanently  the  mouth  of 
the  womb,  so  as  to  allow  a  free  outlet  to  the  secretions, 
which  seemed  to  become  acrid,  by  undergoing  some 
change  while  pent  up  in  the  jDouch  formed  in  the  canal 
of  the  cervix. 

Two  plans  of  operation  were  suggested  to  iny  mind. 
The  first  to  divide  the  os  and  cervix  bilaterally,  and  the 
other  to  remove  the  whole  of  the  posterior  lip  to  h. 
The  first  plan  might  relieve  the  utorrhoea  on  the 
principle  that  we  adopt  in  curing  a  sinus  by  making  a 
capacious  outlet  for  its  contents,  whereby  it  is  kept 
constantly  drained ;  but  I  felt  very  sure  it  would  never 


OS  TINC^— ABNORMAL.  195 

relieve  the  sterility,  because  the  redundant  }.«osterior 
flap  would  always  naturally  over-ride  and  over-lap  the 
anterior  portion,  and  prevent  the  upward  passage  of  the 
spermatozoa ;  and  because  I  had  on  several  occasions 
tried  it  under  like  circumstances  without  success,  and  I 
feared  that  there  would  be  no  permanent  cure  if  the 
sterile  condition  were  not  overcome. 

I  did  not  then  know  of  the  plan  of  splitting  open 
the  posterior  lip  backwards,  as  illustrated  in  fig.  63, 
page  169,  or  I  would,  in  all  probability,  have  adopted 
it  at  the  time.  I  determined,  however,  on  amputation, 
or  exsection  of  the  posterior  portion  of  the  cervix  up 
to  the  dotted  line  h,  as  being  the  best  method  of  both 
insuring  a  good  outlet  for  the  leucorrhoea  and  a  good 
inlet  for  the  semen.  The  operation  was  done  in  April, 
1857,  with  the  assistance  of  Dr.  Emmet  and  Dr. 
Scudder,  then  house-surgeon  at  the  Woman's  Hospital. 
The  patient  left  us  in  a  fortnight,  which  was  entirely 
too  soon  after  such  an  operation,  for  we  were  thus 
deprived  of  using  all  means  to  prevent  an  undue  con- 
traction of  the  OS  by  the  granulating  process.  How- 
ever the  utorrhoea  and  the  pruritus  were  eventually 
cured.  A  conception  in  due  time,  and  a  natural  labour 
at  full  term,  have  proved,  as  far  as  one  case  can,  the 
correctness  of  the  principles  of  the  operation  adopted 
for  the  relief  of  this  and  analogous  cases. 

I  might  go  on  to  enumerate  various  other  modifica- 
tions in  the  size,  form,  and  relations  of  the  os  tincae; 
but  we  have  had  enough  of  this  to  impress  upon  the 
mind  of  the  young  surgeon  the  importance  of  imitating 
nature  as  much  as  possible,  if  we  expect  to  attain  the 
object  of  our  efforts. 


SECTION    IV. 


THE  CERVIX  UTERI  SHOULD  BE  OF  PROPER 
SIZE,  FORM,  AND  DENSITY. 


SECTION    IV. 

THE    CERVIX    UTERI   SHOULD    BE    OF   PROPER   SIZE, 
FORM,    AND    DENSITY. 

Of  250  mai'ried  women  who  had  never  borne  children, 
the  condition  of  the  cervix  was  particularly  noticed  in 
218,  the  remaining  32  being  excluded  on  account  of 
other  complications,  that  would  mar  or  counterbalance 
any  influence  that  the  peculiarities  of  the  cervix  might 
exercise  over  the  sterile  condition.     Of  these  218 — 


The  cervix 
was .  .  . 


Flexed in  19 

„      and  conical »   31 

„  „  and  indurated „   21 


!" 


Straight,  conical,  and  indurated in     4 ' 


„  „  and  elongated    . 

„  elongated,  but  not  indurated  . 
not  conical,  but  hypertrophied  and 
indurated 


Granular 


and  conical 


,,109 
»     7 

„   10 
»     3J 


147 


218 


Now  of  this  number  we  find — 

71  flexed,  of  -which  52  had  a  conical  cervix 
147  straight,      „      123  „  „ 


218 


175 


Thus  we  have  a  conoid  cervix  in  nearly  85  per  cent, 
of  all  cases  of  natural  sterility. 

This  shows  very  plainly  the  great  influence  that  thia 


200  UTERINE  SURaERT. 

peculiar  abnormal  form  of  the  cervix  exerts  over  tlie 
sterile  condition  ;  and  when  we  remember  the  fact  that 
it  is  almost  always  associated  with  a  contracted  os,  we 
are  constrained  to  acknowledge  its  importance. 

Having  said  that  the  cervix  should  be  of  proper  size, 
form,  and  density,  let  us  consider  its  variations  in  size 
from  a  normal  standard. 

It  is  normally  about  half  the  length  of  the  uterus, 
and  projects  into  the  vagina  from  a  fourth  to  the  third 
of  an  inch  anterioi-ly,  and  a  fraction  more  posteriorly. 
The  intra-vaginal  portion  is  rounded,  truncated,  and 
elastic  to  the  touch  ;  but  it  may  vary  from  this  in  many 
particulars.  It  may  be  hypertrophied  or  elongated,  or 
it  may  not  project  into  the  vagina  at  all.  It  may  be 
flexed,  indurated,  engoi'ged,  or  granular  ;  but  in  the 
sterile,  as  shown  in  the  table  above,  it  is  most  frequently 
of  conical  form,  whether  straight  or  flexed  ;  and  with 
the  indurated  conoid  form  there  is,  as  before  said,  almost 
invariably  associated  a  contracted  os. 

But,  independently  of  its  mere  form,  if  the  cervix 
projects  into  the  vagina  a  full  half-inch,  it  is  very  likely 
to  be  associated  with  the  sterile  state ;  if  an  inch,  the 
case  is  almost  necessarily  sterile  ;  if  it  should  be  still 
more  elongated,  say  one  and  a  half  or  two  inches,  it 
becomes  absolutely  so ;  and  if  it  does  not  project  into 
the  vagina  at  all,  it  is  equally  sterile. 

Elongation  of  the  cervix  is  very  common,  while  its 
defective  development  is  comparatively  rare.  This 
elongation  is  sometimes  real  and  sometimes  only  appa- 
rent. It  is  real  when  the  cavity  of  the  uterus  is  more 
than  two  inches  and  a  half  deep,  and  the  additional 
depth  is  seen  to  be  due  to  the  unnaturally  developed 
cervix.  It  is  only  apparently  too  long  when  the  depth 
of  the  cavity  is  normal  and  yet   the   cervix  evident!) 


CERYIX  UTERI— ABNORMAL.  201 

projects  too  far  into  the  vagina,  in  consequence  of  tlie 
vamna  beino:  inserted  too  hiofli  on  the  cervix.  But 
whether  really  or  apparently  too  long,  the  same  treat- 
ment is  necessary.  If  the  elongated  cervix  is  more  than 
an  inch,  the  body  of  the  uterus  will  almost  of  necessity 
be  thrown  backwards,  l)ecause  the  neck  projecting  so 
far  into  the  vagina,  can  only  accommodate  itself  to  the 
opposite  wall,  by  taking  the  direction  of  its  axis.  This 
position  of  the  cervix  must  be  attended  with  a  retro- 
version of  the  body,  or  if  this  be  in  a  normal  position, 
then,  as  a  rule,  the  cervix  must  be  flexed  anteriorly. 
Sometimes  it  may  result  in  complete  procidentia,  but  we 
have  only  now  to  deal  with  the  fact,  and  not  its  conse- 
quences. 

Suppose  we  find  the  cervix  too  long,  what  are  we  to 
do  with  it  ?  Some  of  our  best  authorities  tell  us  to  melt 
it  down  with  the  potassa  c.  calce  or  potassa  fusa  when  it 
is  greatly  hypertrophied.  I  never  tried  to  do  this,  but 
I  have  seen  cases  of  hypertrophy  after  they  were  sub- 
jected to  the  process,  and  I  have  no  hesitation  in  saying 
that  it  is  not  the  safest,  easiest,  and  best  thing  to  be 
done.  What  is  better  then  ?  Amputation  ;  and  for  this 
there  are  two  methods — the  knife  and  the  ecraseur,  the 
former  of  which  1  here  greatly  prefer.  The  objection  to 
the  ecraseur  is  that  it  makes  a  lacerated  surface  to  heal 
by  granulation,  which  takes  a  long  time,  often  leaving 
the  OS  tincae  contracted.  Another  objection  to  it  is  the 
uncertainty  of  amputating  just  where  we  place  the  chain, 
which  often  draws  in  more  tissue  than  we  intend,  and 
removes  more  than  we  wish.  So  great  has  been  this 
trouble,  that  some  of  the  German  surgeons  have  given 
up  the  ecraseur  altogether  in  operations  on  the  neck  of 
the  womb,  because  the  attachment  of  the  bladder  and, 
in  some  instances,  the  posterior  cul-de-sac  of  the  vagina, 


202  UTERINE   SURGERY. 

have  been  injured,  and  even  the  peritoneal  cavity  opened 
by  its  greedy  grasp.  It  might  be  supposed  that  these 
accidents  are  hypothetical,  but  unfortunately  I  can  tes- 
tify personally  to  the  truth  of,  at  least,  one  of  them. 


Fig.  74. 

A  lady  from  Connecticut  was  sent  to  the  Woman's 
Hospital  in  October,  1860,  with  a  cancroid  tumour  of  the 
cervix,  about  the  size  of  a  Sicily  orange.  It  grew  from 
the  whole  cervix.  Fig.  74  is  intended  to  represent  its 
relative  size  and  position.  There  was  no  doubt  as  to  the 
nature  of  the  disease,  nevertheless  it  was  determined  to 
remove  it.  The  patient  was  etherized,  and  placed  on  the 
left  side,  as  in  all  such  operations.  The  speculum  was 
introduced,  and  the  chain  of  the  ecraseur  was  carried 
around  the  base  of  the  tumour,  just  at  the  reduplication 
of  the  vaginal  cul-de-sac  autero-posteriorly,  the  parts  re- 
maining m  'Sitit  as  represented  in  the  diagram. 

The  ecraseur  was  worked  in  the  usual  way;  the  late 
Professor  V.  Mott  was  sitting  on  my  right,  watching  the 
process.     He  had  great  objections  to  the  instrument  on 


CERVIX  UTERI— ABNORMAL. 


203 


philosopliic  grounds,  and  I  was  anxious  to  prove  to  him 
that  it  should  be  accepted  as  a  valuable  addition  to  our 
surgical  resources,  which,  however,  I  failed  to  do.  He 
was  on  the  eve  of  leaving  before  the  operation  was  fin- 
ished, wheti  I  said,  "  Please  wait  a  few  minutes.  Doctor ; 
it  is  almost  through."  He  sat  down  again,  and  in  a 
moment  I  was  surprised  by  the  sound  of  air  rushing  in 
and.  out  of  the  vagina,  with  all  the  regularity  of,  and 
synchronously  with,  inspiration  and  expiration,  at  the 
same  time  that  the  tumour,  obeying  the  slight  traction 
on  the  ecraseur,  came  without  the  least  resistance  to  the 
mouth  of  the  vagina.  Two  or  three  quick  turns  of  the 
chain  cut  it  off  entirely,  and  on  its  removal  I  was  horri- 
fied to  find  an  immense  hole  of  a  semilunar  form,  in  the 
cul-de-sac  of  the  vagina,  through  which  we  could  look 
for  three  or  four  inches  up  into  the  peritoneal  cavity, 
and  observe  the  movements  of  the  viscera  with  every 
respiratory  act. 

Fig.  75  represents  the  appearances  of  the  parts.     The 


uterus  adhered  anteriorly  at  h^  but  posteriorly  and  late- 
rally it  was  completely  severed  from  all   vaginal  con- 


204  UTERINE  SURGERY. 

nections.  To  have  closed  the  parts  properly,  we  should 
have  united  the  edge  of  the  posterior  cul-de-sac  a  to  the 
posterior  portion  of  the  uterus  from  which  it  was  sepa- 
rated ;  but  as  we  all  looked  upon  the  case  as  necessarily 
and  immediately  fatal,  and  as  the  nice  adaptation  of  the 
parts  would  have  been  tedious,  compelling  us  to  keep 
our  patient  longer  under  the  influence  of  ether  than  we 
wished,  we  concluded  to  make  quick  work  of  it.  The 
edges  of  the  vagina  anteriorly,  and  all  the  way  around, 
were  rapidly  denuded,  and  six  silver  sutures  were  passed, 
as  in  the  operation  for  vesico-vaginal  fistula,  and  the  two 
opposite  borders  of  the  vagina  were  neatly  approximated, 
leaving  the  neck  of  the  uterus  within  the  peritoneal 
cavity.  But  for  the  drainage  of  its  secretions  a  catheter 
was  passed  into  the  peritoneal  cavity  at  the  central  point 
of  union  opposite  <?,  which  was  left  slightly  open  for  this 
purpose.  A  severe  peritonitis  followed,  from  which  she 
fortunately  recovered. 

This  operation  was  witnessed  by  a  large  concourse 
of  medical  gentlemen ;  amongst  whom  were  the  venerable 
Dr.  Mott,  Dr.  Emmet,  Dr.  Pratt,  Dr.  Rives,  then  house- 
surgeon,  and  many  others.  It  is  the  only  instance  in 
which  I  have  seen  any  accident  from  the  use  of  the 
ecraseur.  Of  course  the  inclosure  of  the  cervix  within 
the  peritoneal  cavity  was  all  wrong,  and  should  not  be 
done  again  under  similar  circumstances,  and  would  not 
have  been  done  then  if  we  had  had  the  remotest  idea  of 
the  possible  recovery  of  the  patient.  The  peritoneal 
cavity  was  kept  constantly  drained,  by  means  of  the 
tube,  through  which  we  frequently  injected  tepid  water, 
which  gave  great  comfort  to  the  patient. 

It  was  worn  for  about  three  weeks,  when  the  open- 
ing became  fistulous  and  remained  patent.  Greatly  to 
my  surprise,  the   patient  recovered  entirely  from   the 


CERVIX  UTERI— ABNORMAL.  205 

effects  of  the  operation,  and  in  a  few  weeks  returned 
home  in  a  very  comfortable  condition ;  but  soon  symp- 
toms of  the  old  cancroid  disease  began  to  manifest  them- 
selves, and  she  died  of  cancer  some  eight  or  ten  months 
after  leaving  the  Hospital.  The  idea  of  drainage-tubes 
for  the  peritoneal  cavity,  and  of  injecting  this  cavity 
through  them,  belongs  to  my  countryman  Dr.  Peaslee, 
who  has  fully  established  the  safety  and  efficiency  of  the 
practice,  after  the  operation  of  ovariotomy,  where  there 
are  poisonous  secretions  to  be  evacuated.  The  reader 
will  find  Dr.  Peaslee's  cases  reported  in  the  American 
Journal  of  the  Medical  Sciences.^ 

Amputation  of  the  cervix  uteri  belongs  essentially  to 
French  surgery.  It  was  a  very  frequent  operation  in 
the  hands  of  Lisfranc.  He  amputated  the  cervix  in 
ninety-seven  cases,  and  lost  but  two  patients. 

Lately  Huguier  has  brought  it  more  prominently 
before  the  profession  in  generalizing  it  for  all  cases  of 
what  he  terms  hypertrophic  elongation.  His  success  is 
all  that  could  be  desired.  Huguier's  were  all  procidentia 
cases,  mostly  with  elongation  of  the  supra- vaginal  portion 
of  the  cervix  ;  but  we  are  here  to  consider  the  operation 
as  applicable  only  to  infra-vaginal  elongation,  without 
necessarily  a  procidentia. 

In  my  early  amputations  with  the  ecraseur,  the  os 
tincse  was  so  often  puckered  and  contracted,  that  I 
adopted  the  plan  of  doing  the  operation  at  two  periods ; 
thus,  I  would  with  scissors  split  the  cervix  bilaterally, 
nearly  down  to  the  insertion  of  the  vagina,  and  then 
remove  one-half  of  it ;  for  instance,  the  anterior  por- 
tion «,  at  h  (fig.  76) ;  wait  one  or  two  menstrual  periods 


*  American  Journal  of  the  Medical  Sciences,  January,  1856,  p.  49,  April, 
1863,  p.  363 ;  July,  1864,  p.  47. 


206 


UTERINE    SURGERY. 


for  tlie  parts  to  heal,  and  then  remove  the  remaining 
half. 

This  was  getting  to  be  the  method  pretty  generally 
adopted  at  the  Woman's  Hospital  till  October,  1859, 


Fig,  76, 

when  we  hit  upon  the  following  plan  and  in  the  follow- 
ing way.  A  lady  from  North  Carolina  was  sent  to  me 
by  her  physician  for  amputation  of  the  cervix.  Her 
time  being  limited,  she  was  very  anxious  to  return  home 
as  soon  as  possible.  I  therefore  determined  to  remove 
the  whole  cervix  at  one  operation  with  the  ecraseur. 
Just  as  she  was  fully  etherized.  Dr.  Pratt,  the  house- 
surgeon,  reported  that  our  only  ecraseur  was  broken  ; 
and  without  any  choice  in  the  matter,  I  was  compelled 
to  amputate  with  scissors.  By  hooking  a  tenaculum  in 
the  anterior  lip  of  the  os  tinc?e,  the  cervix  was  pulled 
gently  forwards,  and  held  firmly,  while  with  scissors  it 
was  split  bilaterally  nearly  to  the  insertion  of  the  vagina, 
still  holding  on  with  the  tenaculum ;  the  anterior  half 
was  quickly  cut  off  with  scissors  and  then  the  posterior 
half.  I  intended  to  leave  the  stump  to  heal  over  in  the 
usual  way  by  the  granulating  process,  which  would  have 
taken  from  three  to  five  or  six  weeks,  but,  while  examin- 
ing the  wound,  and  waiting  for  the  bleeding  to  cease, 
the  idea  all  at  once  occurred  to  me  to  cover  over  the  cut 


CERVIX  UTERI— ABNORMAL. 


207 


surface  witli  vaginal  mucous  membrane,  just  as  we  cover 
over  the  stump  of  an  amputated  ai'm  or  leg  by  skin,  after 
the  circular  method.  I  immediately  passed  four  silver 
sutures,  two  on  each  side  of  the  canal  of  the  cervix, 
through  the  cut  edges  of  the  vagina,  antero-posteriorly, 
which  drew  this  membrane  over  the  stump  of  the  cervix, 
covering  it  completely,  but  leaving  a  small  oval  opening 
in  the  centre  to  correspond  with  that  of  the  cervical 
canal. 

The  parts  healed  by  the  first  intention  ;  the  sutures 
were  removed  in  nine  or  ten  days,  and  my  patient  was 
soon  on  her  way  home,  not  having  suffei'ed  in  the  least 
from  the"  effects  of  the  operation.  From  that  time  on 
I  have  adopted  this  method  of  amputation,  and  have 
every  reason  to  think  that  the  healing  by  the  first 
intention  in  this  02:)eration  is  relatively  as  superior  to 
that  by  granulation  as  it  is  in  any  other  amputation. 

Fig.  77  represents  the  cervix  after  amputation,  with. 


Fig.  77.  Fig.  78. 

the  wires  passed  through  the  cut  edges  of  the  vagina 
ready  for  covering  over  the  stump. 


208  UTERINE    SURGERY 

Fig.  78  is  to  represent  the  appearance  of  the  stump 
after  the  sutures  are  twisted  and  cut  off. 

But  it  may  be  asked  what  are  the  risks  of  the  opera- 
tion ?  I  think  they  are  few.  Lisfranc  lost  two  patients 
out  of  ninety-seven ;  Huguier  operated  thirteen  times 
without  any  bad  result.  I  have  operated  more  than 
fifty  times,  thirty-six  by  this  method,  and  lost  one 
patient.  This  case  occuri'ed  unfortunately  just  at  a  time 
when  the  hospital  atmosphere  suddenly  became  unfavour- 
able to  all  surgical  operations,  and  we  had  serious  acci- 
dents to  follow  the  slightest  operation,  before  we  were 
aware  that  we  were  breathing  a  poisoned  air.  If  we  had 
known  of  this  epidemic  condition,  this  patient  would  not 
have  been  operated  upon  at  that  time,  for  such  was  the 
state  of  our  over-crowded  wards  that  we  were  oblisfed  to 
thin  them  out,  and  stop  all  operations  for  five  or  six  weeks. 
But  is  there  no  danger  in  the  operation  jper  se  ?  The 
only  one  that  I  know  of  is  that  of  opening  the  perito- 
neal cavity  by  cutting  too  high  up  on  the  posterior  half 
of  the  cervix. 

This  accident  happened  in  the  hands  of  a  very 
accomplished  accoucheur  in  New  York,  and  his  patient 
recovered  without  the  least  bad  symptom.  But,  not- 
withstanding this  fortunate  escape,  it  must  be  looked 
upon  as  a  danger  to  be  carefully  avoided.  Take  this 
method  of  amputation  all  in  all,  I  do  not  think  it  is 
attended  with  any  more  risk  than  that  of  incision  of  the 
OS  and  cervix.  Theoretically  it  should  be  safer,  inasmuch 
as  the  one  is  healed  universally  by  the  first  intention, 
while  the  other  is  an  open  granulating  surface  for  fifteen 
days  or  more.  But  if  offspring  be  very  desirable,  and 
if  a  long  cervix  should  seem  to  be  the  only  or  principal 
barrier,  there  are  but  few  women  who  would  not  take 


CERVIX  UTERI— ABNORMAL. 


209 


tLe  slight  risks  of  the  operation  for  the  fulfilment  of  a 
hope  so  precious. 

I  have  not  as  yet  had  many  cases  of  pregnancy  to 
follow  amputation  of  the  cervix,  but  I  am  well  satisfied 
now,  that  if  amputation  had  been  performed  in  many 
cases  in  which  I  simply  cut  the  open  cervix,  conception 
might  have  occurred,  where  it  has  not. 

On  page  194  is  recorded  a  case  of  pregnancy  follow- 
ing the  amputation,  or  rather  exsection  of  the  posterior 
portion  of  the  cervix ;  and  I  have  another  case  where  it 
followed  the  removal  of  the  anterior  half  of  the  cervix. 
The  circumstances  were  these.  Mrs.  A.,  aged  thirty ; 
married  seven  years;  one  child  six  years  ago;  it  died 
young  ;  no  conception  since  ;  very  anxious  for  offspring; 
exceedingly  unhappy.  A  minute  detail  of  symptoms  is 
unnecessary.  She  had  retroversion,  with  hypertrophy 
of  the  posterior  wall  of  the  uterus ;  while  the  cervix 
was  hypertrophied,  elongated,  and  indurated.  She  was 
under  treatment  at  times  from  October,  1857,  to  the 
spring  of  1859.  From  the  very  beginning  I  told  her  I 
did  not  see  how  she  could  ever  conceive  with  such  a 
condition  of  the  neck  of  the  womb  ;  and  I  wished  then 
to  amputate  it,  but  she  was  afraid  of  the  operation,  and 
could  not  make  up  her  mind  to  it.  At  last  I  told  her 
that  I  could  not  expend  any  more  time  on  her  case, 
unless  she  submitted  to  amputation  of  the  cervix.  She 
consented,  and  entered  the  Woman's  Hospital.  I  was 
then  in  the  habit  of  performing  the  operation  at  two 
periods. 

Dr.  Francis,  Dr.  Mott,  and  Dr.  Green,  of  the  consult- 
ing board,  and  Dr.  Emmet,  were  present  at  the  operation 
on  the  8th  July,  1859.  The  cervix  was  split  bilaterally 
with  scissors,  and  the  anterior  half  was  removed.  She 
left  the  hospital  in  a  fortnight,  with  the  expectation  of 

14 


210  UTERINE  SURGERY. 

returning  on  tlie  1st  of  October  for  the  removal  of  the 
other  half.  But  fortunately  the  next  menstruation  was 
followed  by  conception.  She  went  the  full  term,  and 
was  safely  delivered. 

In  1862  the  greatest  number  of  my  amputations 
were  performed.  It  was  then  a  question  with  many  of 
my  medical  friends  whether  the  operation  would  not  in 
itself  prove  a  barrier  to  conception.  The  case  of  half- 
amputation  above  related,  and  the  one  on  page  194, 
were  then  my  only  facts  bearing  on  the  question.  But 
now  I  have  two  cases  proving  that  it  in  no  way  inter- 
feres with  conception.  It  is  true  that  in  these  the  ope- 
ration was  not  performed  with  any  view  to  conception, 
but  simply  for  the  removal  of  disease  that  baffled  all 
other  treatment.  One  was  a  patient  of  Professor  Met- 
calfe, of  New  York.  She  was  the  mother  of  one  child, 
and  had  been  in  bad  health  ever  since  its  birth. 

The  position  of  the  uterus  was  normal,  the  cervix 
was  hypertrophied,  but  not  indurated,  the  os  was  lace- 
rated back  through  the  posterior  lip,  nearly  to  the  inser- 
tion of  the  vagina,  and  the  cervical  mucous  membrane 
projected  in  voluminous  granular  folds,  giving  rise  to 
constant  leucorrhoea.  Various  remedies  had  been  used 
without  any  improvement ;  and  as  Doctor  Metcalfe  had 
already  exhausted  our  routine  of  local  treatment,  I  pro- 
posed amputation  as  the  speediest  and  surest  method  of 
getting  rid  of  the  diseased  condition,  and  the  operation 
was  done  in  May,  1862,  Dr.  Metcalfe,  Dr.  T.  G.  Thomas, 
and  Dr.  Emmet  assisting.  The  operation  was  performed 
as  already  described,  and  the  stump  covered  over  with 
vaginal  mucous  membrane  bypassing  the  sutures  antero- 
posteriorly.  Haemorrhage  came  on  two  or  three  daj^s 
afterwards,  which  gave  Dr.  Metcalfe  and  Dr.  Thomas  a 
little  trouble ;  but  she  soon  got  well  without  any  other 


CERVIX  UTERI— ABXORMAL.  211 

accident ;  and   Dr.  Emmet  writes  me  that  conception 
occurred  four  mouths  after  the  operation. 

The  other  case  was  that  of  a  lady  who  had  borne  one 
child  four  years  before.  She  is  the  daughter  of  an 
eminent  physician.  She  had  retroversion  with  enlarge- 
ment of  the  posterior  wall,  and  hypertrophic  elongation 
of  the  cervix.  This  condition  of  the  cervix  seemed  to 
be  a  barrier  to  a  rectification  of  the  malj^osition,  and  it 
was  determined  to  amputate  it.  With  the  assistance 
of  Dr.  Emmet  and  Dr.  Pratt,  the  operation  was  per- 
formed in  June,  1862,  and  she  conceived  in  October 
followinor. 

These  facts  I  present  as  an  ansvv^er  to  any  question 
in  regard  to  the  influence  of  amputation  upon  con- 
ception, and  to  show  that  the  operation  jper  se  does 
not  interfere  with  it.  I  have  been  minute  and  a  little 
tedious  in  detail,  because  I  shall  soon  have  occasion  to 
insist  on  the  performance  of  this  operation  in  a  class 
of  cases  where,  as  yet,  it  has  not  been  recommended. 

An  opposite  condition  of  the  cervix,  viz.,  defective 
development,  may  be  a  cause  of  sterility,  and  I  may 
mention  it  in  this  relation.  We  occasionally  find  the 
womb  undeveloped  or  in  quite  a  rudimentary  state,  and 
here  menstruation  may  be  wholly  absent,  or  so  slight 
as  scarcely  to  attract  attention.  In  such  cases  little  or 
nothing  is  to  be  done.  But  now  and  then  we  find  the 
womb  large  enough,  and  menstruation  abundant,  but 
the  cervix  does  not  project  into  the  vagina.  These  are 
always  sterile  and  usually  dysmenorrhoeal.  The  canal 
of  the  cervix  will  be  very  small  and  usually  flexed. 

As  a  type,  I  maj^  give  an  illustration.  Dr.  W.  E. 
Johnston  called  on  me  in  December,  1863,  with  a 
patient  of  his,  who  had  been  married  ten  years  without 
issue.     She   had   consulted  Velpeau,  Nelaton.  Ricord, 


212 


UTERINE  SURGERY. 


Trousseau,  and  thirty-two  other  physicians  of  Paris. 
Her  dysmenorrhoea  was  fearful.  She  usually  took 
anodynes,  and  had  leeches  applied  by  the  speculum 
at  each  menstrual  period.  The  symptoms  and  suffer- 
ings of  such  cases  are  too  well  known  to  require 
detail  here.  The  finger  passed  into  the  vagina,  found 
only  a  blind  pouch,  but  it  was  sufficiently  capacious. 
No  cervix  projected  into  it,  but  the  uterus  could  be  felt 
on  the  right  of  the  mesial  line,  sitting,  as  it  were,  on  the 
vagina,  and  attached  to  it  by  a  narrow  crooked  isthmus 
of  fibrous  tissue,  which  was  the  undeveloped  cervix, 
along  which  a  probe  could  be  passed  to  the  fundus,  a 
depth  of  two  inches  and  a  half.  On  the  left  of  the 
uterus  was  a  mass  of  condensed  cellular  tissue  half 
the  size  of  an  English  walnut,  probably  the  remains  of 
a  pelvic  abscess  that  occurred  some  four  or  five  years 
ago.  The  circle  a  h  (fig.  79)  represents  the  place  that 
should  have  been  occupied  by  the  cervix,  while  the 
point  c  shows  the  actual  opening  leading  to  the  uterus. 


Fig.  79. 


Fig.  80. 


This  point  was  once  more  obscure  than  at  present,  and 
some  one  of  her  physicians  had  split  up  a  bit  of  vaginal 
membrane  that  overlapped,  and  made  the  canal  more 


CERVIX  UTERI— ABNORMAL.  213 

valvular  and  tortuous  than  it  is  now ;  still  this  produced 
no  improvement  in  her  sufferings. 

Fig.  80  shows  the  neck  of  the  womb  resting  on  the 
vagina  instead  of  projecting  into  it.  Of  course  there 
would  be  but  one  course  here  to  pursue,  viz.,  to  cut 
open  the  canal  of  the  cervix,  and  keep  it  open  after- 
wards. But  the  operation  would  require  great  nicety, 
on  account  of  the  narrow  undeveloped  state  of  the 
cervix  just  where  it  comes  in  contact  with  the  vagina. 
However,  nothing  was  attempted  in  this  case ;  she  was 
an  only  child,  and  her  father  was  afraid  to  let  her 
submit  to  a  surgical  operation. 

But  let  us  leave  these  extreme  cases,  whether  of 
hypertrophic  or  defective  development,  and  pass  to  the 
consideration  of  such  conditions  of  the  cervix  as  we 
meet  commonly  and  daily  in  sterile  women. 

At  the  beginning  of  this  section  I  said,  "  the  cervix 
should  be  of  proper  size,  form,  and  density."  Having 
now  spoken  of  the  size  and  its  variations,  we  may  ask 
ourselves  what  is  a  proper  form  or  shape. 

It  should  be  rounded  and  truncated.     Now,  if  we 
turn  back  to  the  table  on  page  199,  we  will  see  that 
of  218  sterile  women  the  cervix  was  flexed  in  Yl.     Of 
these,  10  were  supra- vaginal  curvatures  complicated  with 
some  version  of  the  fundus  from  a  normal  position.    The 
flexure  was  associated  with  a  conoid  form  in  52  cases, 
in  some  of  which  there  were  also  malpositions  of  the 
body.      It  was    straight,  conical,   and  indurated  in  4 
straight,    conical,    indurated,    and    elongated    in    109 
straight,  conical,  elongated,   and   not   indurated  in  7 
granular  and  conical  in  3. 

It  is  thus  shown  that  a  conoid  form  of  the  cervix, 
whether  flexed,  straight,  elongated,  or  not,  is  found  in 
the  great  majority  of  cases  naturally  sterile,  being  here 


214 


UTERINE   SURGERY. 


Fig.  81. 


175  out  of  218.  We  must 
discriminate  between  natural 
and  acquired,  or  accidental 
sterility ;  and  here  let  it  be 
remembered  that  we  speak 
only  of  those  married  women 
who  have  never  conceived. 

I  know  not  how  I  can 
better  describe  what  I  mean 
by  a  conical  cervix  than  by 
diagrams.  Let  fig.  81  re- 
present a  normal  type  of  a 
rounded,  truncated  cervix. 
Now,  if  we  imagine  the 
cervix  extended  in  the  direction  of  the  dotted  line  », 
we  shall  have  a  not  uufrequent  form  of  conoid  cervix, 
which  will  almost  universally  be  associated  with  a  con- 
tracted OS,  and  be  almost  as  constantly  indurated.  A 
moderate  degree  of  conoidity  like  this  may  be  remedied 
very  easily,  and  if  everything  else  is  right,  we  may  cal- 
culate with  a  good  deal  of  certainty  on  the  removal  of 
the  sterility.  For  this  purpose  the  operation  of  incising 
the  OS  and  cervix  as  for  dysmenorrhoea  will  suffice. 
The  operation  does  not  alone  enlarge  the  os,  but  if  the 
circular  fibres  of  the  cervix  be  properly  and  thoroughly 
divided,  the  lips  of  the  os  tiucse,  instead  of  being  puck- 
ered to  a  little  round  point,  evert  and  roll  back  fi'om 
each  other,  giving  the  cervix  more  of  the  natural  feel 
of  a  truncated  cone  than  of  a  pointed  one,  as  before; 
and  thus  while  it  becomes  truncated  it  also  becomes 
shorter,  or,  in  other  words,  while  it  assumes  a  more 
natural  form,  it  also  takes  on  a  more  natural  size. 
This  is  the  mildest  and  most  favourable  of  the  conoid 
form.     Its  tyj^e  is  represented  in  fig.  65,  j).  180.     But 


CERVIX  UTERI— ABNORMAL. 


215 


if  the  cervix  be  extended  in  the  direction  of  the  dotted 
line  ^,  then  its  mere  incision  will  not  so  easily  restore 
it  to  anything  like  a  normal  condition. 

We  sometimes  find  the  cervix  as  conical  as  a  mole's 
head,  gradually  ta23ering  from  the  insertion  of  the 
vagina  almost  to  a  point  at  the  os  tincae,  being  very 
much  longer  than  it  is  broad.  Calling  to  mind  the 
fact  that  in  218  cases  it  was  straight,  conical,  and 
elonofated  in  116,  or  more  than  half,  I  now  think  that 
the  great  mistake  I  have  made  in  the  treatment  of 
these  cases,  was  that  of  simply  incising  the  os  and 
cervix ;  and  the  same  mistake  has  been  made  by  all 
other  sm'o^eons. 

T  now  propose  to  amputate  a  portion  of  the  cervix 
in  all  such  cases,  for  the  purpose  of  giving  it  as  near 
a  normal  form  as  possible.  For  instance,  in  fig.  82,  let 
the  cervix  be  amputated  at  the 
point  designated  by  the  dotted 
line. 

We  have  all  been  afraid  to  trun- 
cate the  cervix  in  this  way  (if  any 
of  us  ever  thought  of  it  before), 
and  were  satisfied  with  simply 
splitting  it  up  for  the  relief  of  the 
pain  of  menstruation,  thinking  that 
if  we  were  successful  in  this  we 
might  hope  for  success  in  other  things.  I  have  cut  open 
the  neck  of  the  womb,  and  often  seen  conception  follow 
soon  after;  and  I  have  cut  open  scores,  nay,  hundreds 
of  others,  sometimes  with  relief  to  suftering ;  but  how 
often  have  I  been  disappointed  in  the  great  object  of  the 
operation  !  And  why  ?  I  now  see  that,  in  many  cases, 
moi-e  must  be  done  than  to  open  the  canal  of  the  cervix. 
When  I  run  my  eye  over  the  list  of  cases  in  which 


Fig.  82. 


21(5  UTERINE  SURGERY. 

the  operation  has  been  quickly  followed  by  conception, 
I  discover  that  while  almost  all  had  a  contracted  os,  all 
had  also  a  cervix  of  no  unusual  lens^th ;  and  when  ] 
examine  closely  all  those  who  have  had  a  division  of 
the  OS  and  cervix  without  its  being  followed  by  con- 
ception, I  find  almost  every  one  of  them  either  with 
an  elongated  conical  cervix,  or  with  some  other  com- 
plication equally  if  not  more  unfavourable.  Does  not 
the  inference  follow  from  this,  that  if  we  expect  to  treat 
such  cases  with  more  certainty  and  greater  success, 
we  must,  other  things  being  equal,  approximate  a  nor- 
mal condition  as  much  as  possible,  by  truncating  the 
cervix  to  a  proper  size  and  form  ? 

It  was  but  the  other  day  I  had  the  opportunity  of 
examining  the  cervix  of  an  unmarried  lady  upon  whom 
I  had  performed  amputation  two  years  ago ;  and  so 
perfectly  normal  was  the  appearance  of  the  os  and 
cervix,  that  there  were  no  evidences  whatever  of  the 
fact  that  an  operation  had  ever  been  done. 

Before  closing  this  subject,  I  may  give  a  few  more 
illustrations  of  the  conical  cervix.  For  instance,  it  may 
be  found  with  a  flexure,  the  anterior  and  posterior 
portions  being  unequally  develoj^ed,  as  in  fig.  83;  and 
here  we  may  cut  open  the  cervix  bilaterally,  or  split 
the  posterior  lip  directly  backwards ;  but  1  think  it 
would  be  much  better  to  amputate  in  the  direction  of 
the  dotted  line,  and  afterwards  to  cut  open  the  cervix 
bilaterally,  if  the  prime  object  of  all  treatment  be 
offspring. 

Again,  we  may  have  the  conical  cervix  with  a 
straight  canal ;  the  whole  organ  having  the  feel  of  a 
hard  inverted  cone  (fig.  84). 

These  cases  I  have  always  cut  open  bilaterally,  but 
I  can  call  to  mind  few  that  were  followed  by  conception. 


CERVIX  UTERI— ABNORMAL.  £17 

In  all  sucli  cases  I  am  now  very  sure  that  it  would  be 
better  to  amputate,  and  restore  the  cervix  at  once  to  a 
normal  condition. 


Fig.  83.  Fig.  84. 

It  is  not  at  all  uncommon  to  find  a  concoid  cervix 
accompanied  with  retroversion.  Sometimes  the  mal- 
position seems  to  be  the  result  of  the  elongated  conoid 
cervix  pressing  against  the  posterior  wall  of  the  vagina. 
Conception  is  impossible  in  a  womb  of  this  relative  size, 
form,  and  position  (fig.  85). 


Fig.  85. 

These  examples  of  conoidity  are  enough  to  Impress 
upon  our  minds  its  general  character  and  appearance  ; 
but  there  are  cases  that  cannot  be  called  conoid,  and 
yet  are  to  be  treated  in  the  same  way  if  we  expect 
offspring.  For  example,  I  saw,  in  consultation  in  Pnris, 
in  May,  1863,  a  lady,  about  27  years  old,  who  had  been 


218  UTERINE   SURGERY. 

married  six  or  seven  years  without  offspring.  She  had 
had  dysmenorrhoea  ever  since  her  marriage,  and  had 
been  treated  by  very  distinguished  physicians,  one  of 
whom  told  her  that  she  might  possibly  fall  into  the 
hands  of  some  surgeon  who  might  wish  to  cut  open  the 
neck  of  the  womb,  against  which  he  would  most 
seriously  protest,  as  an  operation  fraught  with  danger. 
It  is  useless  for  me  to  dwell  upon  her  menstrual  suffer- 
ings, and  general  nervous,  irritable  condition.  There 
was  anteversion,  with  hypertrophic  enlargement  of  the 
fundus  antero-posteriorly,  as  at  a,  h  (fig.  86). 


Fig.  86. 

The  cervix  was  curved,  as  shown  in  the  diagram. 
The  jjosterior  lip  overlapped  the  anterior,  giving  the  os 
a  crescentic  shape.  The  anterior  lip  was  granular.  The 
cervix  was  not,  properly  speaking,  conoid ;  but  it  was 
elongated,  too  long  for  easy  conception,  even  if  it  had 
been  straight  and  patulous.  The  canal  of  the  cervix  could 
not  be  called  contracted,  and  yet  the  flexure  was  such 
as  to  bring  the  antero-posterior  surfaces  in  close  apposi- 
tion, like  laying  the  bowl  of  one  spoon  in  another,  which 
always  presents  a  very  complete  obstruction  to  the 
egress  of  the  menstrual  flow.  As  a  consequence  of  this 
mechanical  barrier,  she  had  a  persistent  endometritis,  as 


CERVIX  UTERI— ABNORMAL.  219 

seen  by  the  dark  brownish  nrncus  that  was  always  found 
han<i:iiicf  from  the  cervical  canal. 

I  here  proposed  to  divide  the  cervix  bilaterally,  at 
the  same  time  saying  that  amputation  would  give  us  a 
better  chance  for  permanent  relief. 

Her  medical  attendant  agreed  to  the  operation  of 
incising  the  os  and  cervix.  Our  object  was  to  relieve 
the  dysmenorrhoea  and  endometritis  by  opening  the 
canal,  knowinir  full  well  that  it  would  be  a  most  difBcult 
thing  to  render  it  permanent  unless  we  could  keep  the 
posterior  lip  everted  or  rolled  backwards.  However, 
the  operation  was  thus  performed,  much  against  the 
wishes  of  the  patient  herself,  who  begged  for  amputa- 
tion, as  affording  her  the  surest,  if  not  the  safest,  method 
of  cure.  Her  first  menstruation  after  the  operation  was 
entirely  painless,  but  unfortunately  it  did  not  remain  so, 
and  further  treatment  was  necessary.  In  cases  like 
this  I  am  sure  it  would  be  better  to  amputate  the  cervix 
first,  and  then  incise  it  at  some  subsequent  period. 

If  experience  should  prove  that  I  am  correct  in  my 
views  in  regard  to  the  necessity  of  amputating  an 
elongated  conoid  cervix,  for  the  purpose  of  augmenting 
the  chances  of  conception,  1  feel  that  it  is  important  to 
simplify  the  operation  as  much  as  possible.  The  ampu- 
tation of  the  cervix  by  scissors,  as  I  have  always  done 
it,  is  easy  enough  in  the  hands  of  a  practised  surgeon,  but 
every  one  will  not  find  it  always  so  easy  to  make  a  good 
even  stump  by  this  method.  I  have  not  been  able  to 
get  a  pair  of  scissors  curved  sufficiently  to  do  the  woi-k 
neatly.  But  I  think  I  have  at  last  hit  upon  something 
better,  which  I  would  term  the  uterine  guillotine.  This 
instrument  is  made  in  London  by  Mayer,  and  in  Paris 
by  Charri^re.  The  idea  of  the  uterine  guillotine 
occurred  to  me  in  this  way.     In  July  last  (1865)  my 


220  UTERINE  SURGBRT. 

friend  Dr.  Henry  Bennet  invited  me  to  amputate  ai 
elongated  hypertropliied  cervix  in  a  patient  of  his  who 
had  had  procidentia  for  a  long  time.  The  cervix  pro- 
jected from  the  vulva  about  an  inch  and  a  half  It  was 
necessary  to  remove  three-fourths  of  an  inch  of  it.     Dr. 


Fig.  87. 

Bennet  held  the  uterus  firmly  with  a  double  tenaculum 
forceps  (fig.  87),  seizing  the  cervix  antero-posteriorly, 
just  above  the  point  of  election  for  the  amputation.  I 
then  caught  hold  of  the  end  of  the  cervix,  and  with  a 
bistourie  cut  it  instantly  off.  The  stump  was  covered 
over  with  mucous  membrane  in  the  usual  way  with 
silver  sutures.  The  operation  was  done  so  quickly  and 
withal  so  neatly,  that  I  immediately  said,  "Why  should 
we  not  have  an  instrument,  like  those  for  the  tonsils, 
to  amputate  the  cervix  all  at  once,  while  the  organ  is  iii 
situP'  This  idea  I  gave  to  Mr.  Mayer,  and  fig.  88 
represents  the  instrument.  It  consists  simply  in  adding 
a  blade  to  the  ecraseur.  At  first  I  had  a  wire  to  con- 
strict the  part  to  be  amputated,  but  I  found  that  it 
would  bend  a  little  from  a  right  line  when  tightened, 
and  so  strike  the  edge  of  the  knife  as  it  was  pushed 
forwards ;  then,  at  M.  Charriere's  suggestion,  a  loop  of 
narrow  watch  spring  doubled  three  or  four  times  was 
substituted,  giving  a  flat  surface  along  which  the  blade 
glides  without  obstruction. 


CERVIX  UTERI— ABNORMAL. 


221 


Ji 


111  applying  the  instrument,  let  the  loop  f  encircle 
the  cervix  where  we  wish  to  cut  it  off ;  ^ 

turn  the  screw-nut  h  till  the  loop  em- 
braces the  part  firmly  and  immovably ; 
transfix  the' cervix  with  the  needle  by 
means  of  the  slide  d ;   then  push  the 
blade  e   quickly  forwards  by  forcing 
down  the  shaft  a^  and  the  part  will  be 
instantly    cut    through.     The    dotted 
lines  l^  e,  j  show  the  relations  of  the 
loop,  needle,  and  knife,  when  the  opera- 
tion is  finished.     The  patient  is  to  be, 
of  course,  in  the  left  lateral  semi-prone 
position,  and  the    operation   executed 
without  traction  on  the  uterus.     The 
stump   is   to    be    covered   over    with 
mucous  membrane,   as  previously  de- 
scribed and  figured  (p.  207).     There  is 
always  some  contraction  of  the  os  ex- 
ternum  after  all   amputations    of  the 
cervix.     It   is  better  as  a  rule  to  let 
things  take  their  course,  and  in  two  or 
three  months  afterwards  cut  open  the 
OS  and  cervix,  and  treat  it  just  as  we 
would   under   ordinary   circumstances 
requiring   such    an  operation.     If   we 
attempt  to  keep  the  os  normally  open, 
there  is  danger  of  interfering  with  the 
covering  of  the  stump ;  and  if  we  re- 
sort to  the  operation  of  incising  it  too 
soon    after   the    amputation,    say   just 
after  the  next  menstrual  flow,  we  may 
in  our  manipulations  tear  tlie   vaginal 
covering  of  the  stump  from  the  surface  to  which  it  has 


Fig.  88. 


222  UTERINE  SURGERY. 

recently  adhered.  I  have  had  this  accident  happen 
in  my  own  hands;  and  hence  the  warning  to  guard 
against  it. 

Induration  of  the  cervix  is  so  often  an  attendant  of 
the  sterile  condition  that  it  is  appropriate  to  speak  of  it 
here  in  connection  with  the  size  and  form  of  the  cervix. 
It  may  be  natural  or  acquired  ;  natural  when  we  find  a 
little  gristly-feeling  cervix  in  a  dysmenorrhoeal  case, 
where  there  is  often  a  small  fibroid  in  the  anterior  wall 
of  the  uterus ;  acquired,  when  we  find  it  following  a 
chronic  inflammation  of  the  cervix,  in  which  the  granular 
condition  disappears  after  a  very  long  time  and  perhaps  a 
long  treatment.  I  have  no  specific  treatment  to  suggest, 
and  I  look  upon  it  as  important,  more  particularly  as  it 
may  influence  the  size,  form,  and  relations  of  the  os  and 
cervix.  If  there  is  a  deposit  of  fibrous  tissue  in  the 
cervix,  as  a  result  of  inflammatory  action,  I  know  of  no 
sho]-t  way  of  causing  its  absorption,  and  I  deal  with  it 
only  incidentally,  as  my  attention  is  dii'ected  to  the  rec- 
tification of  the  anatomical  and  mechanical  peculiarities 
already  discussed.  I  know  that  physicians  give  altera- 
tives, absorbents,  and  general  constitutional  remedies, 
and  apply  all  sorts  of  things  locally ;  that  they  melt 
down  the  cervix  with  potassa  cum  calce ;  but  even  then 
the  induration  remains ;  and  I  would  prefer  immediate 
amputation  to  this  tedious  uncertain  process.  It  is  sup- 
posed that  the  drain  of  the  caustic  issue  softens  the 
parts ;  but  I  have  not  seen  it  so,  and  some  years  ago  I 
often  used  this  potent  agent.  I  must  say,  however,  that 
Professor  Fleetwood  Churchill's  iodine  treatment  has  in 
my  hands  produced  a  greater  amelioration  in  these  cases 
than  anything  else;  but  it  is  tedious.  Dr.  Churchill 
tells  me  that  I  have  failed  with  it  because  I  have  not 
persevered  long  enough  in  its  use.     I  beg  leave  here  to 


CERVIX  UTERI— ABNORMAL.  223 

refer  tlie  reader  to  his  learned  and  classic  work  on  the 
Diseases  of  Women  for  minute  information  on  this 
point. 

Dr.  Barnes  has  recently  (June  7th,  1865)  presented 
a  paper  to  the  London  Obstetrical  Society,  in  which  he 
discusses  very  ably  the  infl-ience  exercised  by  the  conoid 
cervix  upon  the  sterile  condition.  The  following  sum- 
mary* is  extracted  from  the  report  of  the  Secretary, 
Dr.  Meadows  : — "  Dr.  Barnes  described  and  fisrured  the 
form  of  cervix  uteri  wliich  projected  into  the  vagina  as 
a  conical  body,  the  vagina  appearing  to  be  reflected  off 
at  a  point  nearer  the  os  internum  than  normal.  The  os 
externum  was  unusually  minute,  scarcely  admitting  the 
uterine  sound.  This  (the  os  externum)  was  the  real 
seat  of  constriction.  The  os  internum  was  normally  a 
narrow  opening,  and  in  these  cases  of  dysmenorrhoea 
and  sterility  it  was  commonly  found  to  be  of  normal 
character.  It  was  therefore  unnecessary  to  divide  it.  It 
was,  moreover,  dangerous  to  divide  it,  on  account  of  the 
close  proximity  of  the  large  vessels  and  plexuses  run- 
ning: into  the  uterus  on  a  level  with  it Discussino; 

the  question  of  treatment.  Dr.  Barnes  showed  that  dila- 
tation was  unsatisfactory ;  that  incision  of  the  os  inter- 
num as  practised  by  Dr.  Simpson's  single  bistourie  cache, 
and  by  Dr.  Greenhalgh's  double  bistourie  cache,  was 
unsafe  and  supei'fluous.  He  objected  to  the  latter  instru- 
ment, especially  that  it  must  cut  as  it  was  set,  that  it 
was  too  much  of  an  automatic  machine,  not  leaving 
scope  for  the  judgment  of  the  operator.  His  (Dr. 
Barnes's)  own   instrument,  constructed   like  a  pair   of 


*  Lancet,  July  15th,  1865  :  "  On  the  Dysmenorrhoea,  Metrorrhagia,  Ovari- 
tis, and  Sterility  asi-ociated  with  a  Peculiar  Form  of  the  Cervix  Uteri,  and 
the  Treatment  by  Division."     By  Robert  Barnes,  M.D. 


224  UTERINE   SURGERY. 

scissors,  acted  on  the  same  principle  as  Dr.  Sims's  ;  it 
divided  only  the  os  externum,  so  as  to  open  the  cavity 
of  the  cervix,  the  part  to  be  cut  being  first  seized 
between  the  two  blades.  The  operation  was  perfectly 
free  from  risk ;  the  haemorrhage  was  usually  slight,  and 
a  good  OS  was  made.  He  had  performed  the  operation 
many  times,  both  in  hospital  and  private  practice,  and 
was  well  satisfied  with  the  results.  One  advantage  of 
incision  over  dilatation  was,  that  it  relieved  the  engorge- 
ment and  inflammation." 

Dr.  Barnes's  admirable  paper  gave  rise  to  a  length- 
ened discussion  ;  he  and  Mr.  Baker  Brown  alone,  amongst 
all  the  speakers,  holding  the  same  views  that  I  do  in 
regard  to  the  relative  infrequency  of  contraction  at  the 
OS  internum  as  compared  with  that  at  the  os  externura. 


SECTION   V. 


THE  UTERUS  SHOULD  BE  IN  A  NORMAL  POSITION— 
i.  e.,  NEITHER  ANTEVERTED  NOR  RETROYERTED 
TO  ANY  GREAT  DEGREE. 


16 


SECTION   V. 

THE     UTERUS    SHOULD     BE    IN"     A     NORMAL    POSITION i.  6.^ 

NEITHER  ANTEVERTED  NOR  RETRO  VERTED  TO  ANY  GREAT 
DEGREE. 

Before  treating  of  displacements  of  the  uterus,  let  us 
first  fix  in  our  minds  a  correct  idea  of  its  normal  position 
and  relations.  Not  wishing  to  write  one  unnecessary 
page,  I  "shall,  as  hitherto,  avoid  minute  anatomical  and 
histolos^ical  detail,  which  can  be  better  learned  from  anv 
of  our  text-books.  I  would  say,  however,  that  some  of 
the  discrepancies  of  authors  may  be  reconciled  when  we 
remember  that  one  speaks  of  the  condition  of  things  in 
the  living  subject,  and  another  in  the  dead.  Thus,  one 
will  tell  us  that  the  uterus  is  about  two  and  a  half  inches 
deep,  while  another  will  say  it  is  less.  Both  are  right ; 
for  the  uterus,  an  erectile  organ,  full  of  blood,  is  larger 
and  longer  in  the  living  body  than  in  the  dead.  The 
knowledge  of  one  is  gained  in  the  clinic ;  of  the  other  in 
the  dissectinof-room. 

o 

I  do  not  know  of  any  anatomical  plates  that  repre- 
sent correctly  the  position  and  relations  of  the  pelvic 
organs.  The  artist  has  not  succeeded  perfectly  in  this 
cut  (fig.  89),  but  it  is  near  enough  to  give  us  a  good 
general  idea  of  the  subject. 

[I  was  at  great  pains  to  get  a  correct  outline  of  a 
vertical  section  of  the  pelvic  bones  as  here  shown.  For 
this  I  am  under  special  obligations  to  M.  Pean,  of  Paris, 
Prosecteurdes  Hopitaux,  who  politely  afibrded  me  every 
facility  at  Clamart,  both  in  its  museums  and  dead-house ; 


228 


UTERINE   SURGERY. 


also  to  my  talented  young  friend  Edward  Souclion,  of 
New  Orleans,  Louisiana,  who  made  for  me  repeated  dis- 
sections, which  were  photographed,  and  from  which  Mr. 
Vien  made  the  drawing,] 


Fig.  89. 

The  uterus  occupies,  normally,  very  nearly  a  central 
position  in  the  pelvis,  being,  perhaps,  a  little  nearer  to 
the  sacrum  than  to  the  pubes.  Its  long  axis  should 
stand  at  about  right  angles  to  that  of  the  vagina  ;  the 
fundus  pointing  in  the  direction  of  the  umbilicus,  and 
the  OS  tincaB  towards  the  end  of  the  coccyx.  The  fun- 
dus may  be  tilted  a  little  one  way  or  the  other  without 
the  position  being  necessarily  abnormal.  The  condition 
and  contents  of  the  bladder  and  rectum  may  temporarily 
influence  it  to  some  extent.  If  it  turn  forwards  pr  back- 
wards for  25^  or  30°^  it  does  not  amount  to  a  malposi- 
tion ;  but  if  to  40°  in  either  direction  without  soon  recti- 
fying itself,  it  is  abnormal,  and  usually  goes  from  bad  to 
worse,  till  the  malposition  becomes  persistent.  A  glance 
at  the  cut  will  show  us  that  if  the  uterus  fall  backwards 
in  a  line  drawn  from  the  os  to  the  promontory  of 


omoutory  of  ^i^^ 


UTERINE  DISPLACEMENTS.  229 

sacrum,  it  will  describe  an  angle  of  45°,  and  will  present 
its  broadest  surface  to  the  pressure  of  the  superincumbent 
viscera,  w^hich  will  necessarily  force  it  eventually  lower 
and  lower ;  and  if  it  turn  forward  to  the  same  extent,  the 
same  power  exerted  on  its  broad  posterior  surface  neces- 
sarily increases  this  abnormal  tendency.  But  an  antever- 
sion  never  goes  relatively  to  so  great  an  extent  as  a 
retroversion,  simply  because  it  meets  with  more  resist- 
ance. Anteversion  often  stops  at  45^^,  but  may  go  to 
90^^,  as  when  we  have  a  complete  version,  with  the 
whole  organ  lying  flatly  down  on  the  anterior  wall  of 
the  vagina,  and  parallel  with  it,  while  a  retroversion  sel- 
dom or  never  stops  under  90°,  and  often  goes  to  135°, 
simply  because  there  is  less  opposition  to  its  downward 
progress. 

It  then  follows  that  if  the  fundus  of  the  uterus  is 
found  constantly  lying  just  behind,  or  even  near,  the 
symphysis  pubis,  it  is  an  suite  version  ;  but  if  it  is  found 
lying  persistently  back  under  the  promontory  of 
the  sacrum,  it  is  a  retroversion.  But  when  only  the 
body  of  the  uterus  is  tui-ned  forwards  or  backwards,  the 
OS  seemins:  to  be  in  rather  a  normal  relation  with  the 
vagina,  there  is  necessarily  a  bending  of  the  cervix  some- 
where between  the  os  externum  and  the  os  internum, 
and  we  call  this  a  flexion.  Most,  l)ut  not  all,  versions 
become  flexions ;  so  that,  as  a  general  rule,  they  are 
but  different  stages  or  degrees  of  the  same  thing.  I 
have  not,  therefore,  thought  it  of  practical  importance 
to  say  that  out  of  so  many  anteversions  and  retrover- 
sions, there  was  such  a  proportion  of  flexions,  simply 
because  these  distinctions  will  not  modify  the  general 
princi})les  of  treatment. 

Time  was,  and  not  very  long  ago,  when  the  diagnosis 
jiterine  displacements  was  attended  with  great  difla- 


-  of— uterine  dispL 


230  UTERINE  SURGERY. 

culty,  but  tliere  is  notliing  easier  uow.  Fcrmerly,  all 
uterine  disease  was  known  under  the  sweeping  term  of 
prolapsus ;  a  term  that  has  been  used  so  vaguely  and 
indefinitely  that  it  should  he  banished  from  uterine  tech- 
nology ;  for  in  England  it  is  applied  to  a  descent  of  the 
organ  through  the  vulvar  outlet,  while  in  my  own  coun- 
try it  is  often  applied  to  its  various  intrapelvic  devia- 
tions. Formerly,  if  any  woman  here  had  a  little  vesical 
tenesmus  with  a  constant  sense  of  weight  in  the  pelvis, 
and  bearing  down,  it  was  called  a  prolapsus  ;  but  now 
we  know  very  well  that  these  symptoms  may  exist  as  a 
sign  of  engorgement,  or  granular  erosion  of  the  os, 
without  the  least  displacement  of  the  organ. 

To  be  accurate,  then,  the  malposition  should  be  ascer- 
tained exactly,  and  we  should  apply  to  it  the  term  that 
would  express  precisely  the  deviation  from  a  normal 
position.  If  we  use  the  term  retroversion,  of  course  we 
all  understand  it,  because  its  meanins^  is  defined.  If  we 
say  anteversion,  for  the  same  reas6n,  there  can  certainly 
be  no  misunderstanding.  If  we  say  antero-lateral  version, 
it  is  equally  significant  of  the  position,  provided  we  add 
the  qualifying  adjectives,  right  or  left,  as  the  case  may 
be.  If  we  say  procidentia,  we  mean  that  the  cervix 
uteri  has  passed  beyond  the  mouth  of  the  vagina,  to  a 
greater  o-r  less  degree ;  but  to  say  there  is  prolapsus  is 
to  hide  up  the  real  condition  of  the  uterus  under  a  vague 
generality.  I  therefore  use  the  terms  anteversion  and 
retroversion  to  designate  the  relative  deviations  of  the 
body  of  the  uterus  from  a  normal  position  while  within 
the  pelvic  cavity,  and  the  term  procidentia  to  designate 
its  passage  out  of  the  pelvis  through  the  mouth  of  the 
vagina. 

Ante  versions  are  often  du^  to  adventitious  develop- 
ment of  some  sort  in  the  anterior  wall;  retroversions 


;'U' 


UTERINE  DISPLACEMENTS. 


231 


frequently  occur  as  a  sequence  of  debility,  or  relaxation 
in  the  ligaments  that  support  the  uterus.  In  both  we 
often  find  an  enlargement  of  that  portion  of  the  body 
which  is  most  dependent.  In  the  first,  this  enlarge- 
ment frequently  induces  the  deviation;  in  the  second, 
it  is  oftener  the  consequence  of  it. 

When  we  remember  that  about  every  eighth  mar- 
riage is  sterile,  we  see  the  necessity  of  investigating  all 
particulars  that  can  by  any  possibility  bear  upon  the 
elucidation  of  this  important  subject.  At  the  beginning 
(page  2)  I  said  that  I  had,  for  obvious  reasons,  divided 
my  sterile  patients  into  two  classes ;  viz.,  natural,  and 
acquired  sterility.  The  following  table  shows  at  a 
glance  what  an  influence  mere  displacements  of  the 
uterus  must  exercise  over  the  sterile  condition  in  each 
of  these  classes : — 


cLi.  Anteverslons.  Eetroversions.        ^J^^J,,, 


Anteverslons. 

Eetroversions. 

103 

68 

61 

111 

1st  Class 250  103  68  171 

2nd  Class 255  61  111  172 

Total 505  164  179  343 

Thus  we  see  in  250  married  women,  who  had  never 
borne  children,  that  103  had  ante  version,  and  68  retro- 
version ;  while  in  255  who  had  once  borne  children, 
but  for  some  reason  ceased  to  conceive  before  the 
natural  termination  of  the  child-bearing  period,  61  had 
anteversion,  and  111  retroversion,  the  sum  total  in  each 
class  bearing  almost  exactly  the  same  relation  to  the 
number  observed,  being  about  two-thirds  of  the  whole. 
Hence  we  infer  that  if  the  malposition  exercises  an 
influence  to  prevent  conception  in  the  one  class,  it  is 
of  equal  importance  in  preventing  it  in  the  other.  The 
mere   position  of  the   uterus    is    here   stated   without 


232  UTERINE  SURGERY. 

reference  to  causes  or*  complications.  1  have  purposely 
avoided  saying  how  many  of  these  had  granulations, 
engorgements,  hypertrophies,  fibroids,  ovai'ian  cysts,  or 
other  complications.  The  table  shows  that  two-thirds 
of  all  sterile  women  labour  under  some  form  of  uterine 
displacement,  without  reference  to  the  particular  cause 
of  such  displacement;  and  that  the  anteversions  and 
retroversions  in  the  two  classes  are  in  inverse  propor- 
tion :  the  anteversions  in  the  first  being  about  equal  to 
the  retroversions  in  the  second ;  and  the  retroversions 
of  the  first  nearly  the  same  as  the  anteversions  of  the 
second. 

Without  further  general  remarks,  let  us  proceed  to 
consider  in  turn  these  various  forms  of  displacement. 
I  have  not  thouo;ht  it  worth  while  to  make  a  distinct 
heading  for  antero-lateral  flexions.  They  comprise  but 
a  small  class,  and  are  almost  always  secondary,  being 
the  result  of  some  other  alBfection. 

Of  Anteveesion. — According  to  the  tabulated  state- 
ment above,  nearly  one-third  of  all  sterile  women  have 
anteversion.  In  natural  sterility  the  proportion  is  1 
in  2*42 ;  in  acquired,  it  is  1  in  4*18,  being  nearly  twice 
as  frequent  in  the  first  as  in  the  second. 

It  would  here  be  appropriate  to  lay  down  the  rules 
of  diagnosis  in  reference  to  this  particular  form  of  dis- 
placement ;  but  as  its  principles  have  been  already 
amply  stated,  whether  by  bi-manual  palpation  or  probing 
(see  pages  7,  8,  and  101  to  105),  it  is  unnecessary  to 
repeat  them  here.  I  will  now  only  say  that  we  are  never 
under  any  circumstances  to  probe  the  uterine  cavity  till 
we  have  by  the  touch  first  ascertained  its  probable  direc- 
tion ;  and  then  the  sound  is  to  be  curved  or  not,  accord- 
ing to  the  suspected  curvature  of  the  canal  of  the  cervix. 


UTERINE  DISPLACEMENTS.  238 

Anteversion  may  depend  upon  a  variety  of  causes ; 
sometimes  the  uterus  seems  to  be  bent  upon  its  own 
axis,  in  consequence  of  an  abnormal  elongation  of  the 
organ.  For  instance,  suppose  tlie  sound  passes  three 
inches  and -a  half  into  the  cavity  of  the  uterus,  we 
would  then  say  it  is  at  least  an  inch  too  long.  This 
must  depend  upon  one  of  three  things:  either  an  elonga- 
tion of  the  intra-vaginal  j^ortion  of  the  cei'vix ;  elonga- 
tion of  the  supra-vaginal  portion ;  or  hypertrophy  of  the 
fundus.  If  on  the  first,  the  touch,  sight,  and  absolute 
measurement  will  at  once  determine  it ;  if  on  the  second, 
the  unerring  bi-manual  palpation  will  demonstrate  to 
our  sense  of  touch,  a  long,  delicate,  slender,  flexible 
supra- vaginal  cervix; 'if  on  the  third,  it  can  be  equally 
as  well  measured  and  judged  by  the  touch  alone,  pro- 
vided we  apply  the  principles  of  diagnosis  already  re- 
ferred to. 

We  sometimes  find  the  uterus  undeveloped,  entirely 
too  small,  often  not  more  than  an  inch  and  a  half  deep; 
and  again,  it  is  not  uncommon  to  find  it  over-developed, 
with  the  supra-vaginal  portion  of  the  cervix  long  and 
slender ;  and  when  this  is  the  case,  the  fundus  must 
of  necessity  fall  one  way  or  another,  and  most  usually 
forwards,  producing  anteversion  or  flexion. 

Again,  anteversion  seems  to  be  occasionally  the  re- 
sult of  a  shortening  of  the  utero-sacral  ligaments ;  or  else 
these  ligaments  become  shortened  by  the  long-continued 
malposition.  Nothing  is  moi'e  common  in  old  retrover- 
sions than  to  see  the  anterior  wall  of  the  vagina  con- 
tracted in  consequence  of  the  long-continued  malposi- 
tion; and  here  it  often  presents  a  formidable  barrier 
to  a  permanent  rectification  of  the  displacement.  Now 
in  the  same  way  it  is  presumable  that  the  utero-sacral 
ligaments,  if  not  congenitally  too   short,   may  become 


234  UTERINE    SURGERY. 

shortened  by  long  disuse,  just  as  the  round  ligaments 
may  become  relaxed  and  lengthened  by  long  error  of 
position. 

Be  this  as  it  may,  we  sometimes  meet  with  ante- 
versions  where  we  encounter  great  difficulty,  and  inflict 
great  pain  in  drawing  the  os  tincae  forwards.  In  these 
cases  the  vagina  is  long  and  narrow,  and  the  os  tinc^, 
instead  of  pointing  towards  the  end  of  the  coccyx,  may 
look  directly  back  towards  the  hollow  of  the  sacrum. 

Now,  if  we  here  insert  a  tenaculum  into  the  anterioi 
lip  of  the  OS  tincsB,  and  pull  it  towards  the  urethra,  feel- 
ing at  the  same  time  unusual  resistance  to  this  traction, 
there  will  be  one  of  two  things  to  account  for  it :  either 
the  fundus  of  the  uterus  is  bound  down  anteriorly  by 
adhesions,  or  the  cervix  is  held  back  posteriorly  by 
shortened  utero-sacral  ligaments.  If  the  first,  which  is 
very  rare,  then  it  will  be  impossible  to  elevate  the  fun- 
dus to  a  normal  position  by  the  usual  method  of  elevat- 
ing the  anterior  cul-de-sac  of  the  vagina  up  behind  the 
inner  face  of  the  pubes  with  the  left  index  finger,  while 
the  fundus  is  pushed  backwards  by  the  other  hand  act- 
ing upon  it  in  the  hypogastrium  through  the  parietes 
of  the  abdomen ;  but  if  it  be  due  to  the  second,  then, 
by  introducing  the  index  finger  into  the  rectum,  or  even 
to  the  posterior  cul-de-sac  of  the  vagina,  at  the  same 
time  that  we  draw  down  the  cervix  with  the  tenaculum, 
we  shall  feel  the  utero-sacral  ligaments  as  tense  and 
resistent  as  two  well-stretched  guitar-strings.  I  must 
admit  that  such  cases  are  not  very  common ;  but  their 
infrequency  makes  it  the  more  important  to  be  able  to 
recognize  them  when  we  meet  with  them. 

One  of  the  most  common  causes  of  anteversion  is  a 
small  fibroid  in  the  anterior  wall,  as  represented  in  fig. 
00.     It  is  very  interesting  to  observe  the  influence  of 


UTERINE    DISPLACEMENTS. 


235 


sucli  tumours  in  producing  the  various  displacements 
of  the  uterus.  If  a  fibroid  not  larger  than  an  English 
walnut  is  attached  in  any  way  to  the  posterior  wall  of 
the  uterus  above  the  level  of  the  os  internum,  it  almost 
invariably  pulls  the  uterus  over  backwards,  producing 
retroversion ;  but  if  a  similar-sized  tumour  is  attached 
to  the  posterior  wall  of  the  uterus  below  the  level  of  the 
OS  internum,  whether  it  be  pedunculated  or  not,  it  will 
almost  as  invariably  push  the  fundus  of  the  uterus  over 
forwards,  or  produce  anteversion.  In  other  words,  a 
small  tumour  of  the  body  of  the  uterus  posteriorly  will 
produce  retroversion,  while  the  same  sized  tumour  of  the 
cervix  posteriorly  will  produce  anteversion  ;  and  vice 
versa.,  a  small  tumour  in  the  anterior  wall  of  the  body 
anteverts  the  uterus,  but  if  it  grow  anteriorly  below  the 


Fig.  90, 


¥ni.  91. 


level  of  the  os  internum,  it  invariably  retroverts  it. 
The  reasons  are  anatomical  and  most  obvious.  Let  fisr. 
9 1  represent  the  uterus  in  its  normal  relations  wit  h  the 
axis  of  the  vagina.  A  small  tumour  on  the  posterior 
wall  at  a  will,  as  before  said,  retrovert  the  uterus,  but  a 
similar-sized  one  attached  low  down  on  the  cervix  at  h 
will  as  invariably  antevert  it.     In  the  first  instance  the 


236  UTERINE  SURGERT. 

uterus  obeys  the  laws  of  gravity,  by  whicli  an  additional 
weight  on  one  side  of  the  fundus  must  pull  it  in  the 
direction  of  said  force  ;  while  in  the  second  instance,  the 
tumour  finds  a  point  d''ap])id  in  the  utero-sacral  liga- 
ments, rectum,  and  cul-de-sac  of  the  vagina,  which 
oppose  its  downward  pressure ;  and  thus,  as  the  tumour 
grows,  it  gradually  pushes  the  fundus  forwards. 

For  the  same  reasons  a  tumour  anteriorly  at  d^  as  a 
rule,  anteverts,  while  one  at  c  invariably  retroverts 
the  uterus,  because  it  finds  a  point  of  resistance  in  the 
walls  of  the  bladder  at  its  junction  with  the  cervix. 
Another  reason  for  this  curious  law  of  displacement 
in  consequence  of  small  growths  on  the  supra-vaginal 
cervix  may  be  found  in  the  fact  that  the  tumour  acts 
like  a  splint  upon  the  side  of  the  naturally  slender  and 
flexible  cervix.  These  rules  are  applicable  to  small 
tumours  only,  and  all  tumours  must  have  had  a  small 
beginning.  When  they  grow  large  enough  to  rest 
upon  the  brim  of  the  pelvis,  they  elevate  or  depress 
the  body  of  the  uterus  more  by  their  volume  and  rela- 
tions to  the  pelvic  cavity  than  by  the  mere  place  of 
their  accidental  attachment. 

I  have  in  many  instances  seen  the  cervix  curved, 
anteriorly  where  it  seemed  to  be  produced  by  an  amor- 
phous growth  on  its  posterior  surface.  The  relative 
position  and  outline  of  this  anomalous 
projection  is  represented,  in  fig.  92,  a. 
I  do  not  know  what  to  call  it ;  it  is 
not  a  fibroid  tumour.  To  the  touch 
it  has  a  fibro-cartilaginous  feel  :  I 
suppose  I  have  seen  a  dozen  cases  of 
it.      It    is   very   uniformly   of    the 

Fig.  92.  1      P  1 

shape   and    form    here   represented, 
always   pointed    below  ;   it   almost  always  projects,  as 


UTERINE  DISPLACEMENTS.  237 

here,  a  little  below  the  insertion  of  the  vagina.  I 
have  never  found  anything  like  it  growing  on  any 
other  portion  of  the  litems.  I  have  seen  it  in  two  cases 
in  which  there  was  no  curvatui'e  of  the  cervix.  Each 
of  these  was  sterile,  each  had  the  cervix  incised  ;  one 
conceived  four  months  afterwards,  the  otjier  in  eight. 
Both  of  these  had  had  metro-peritonitis  some  time  before 
I  saw  them.  From  these  two  cases  we  may  infer  that 
this  growth  may  possibly  be  the  product  of  inflamma- 
tory action,  and  that  it  does  not,  'per  66',  interfere  with 
conception  and  child-bearing.  In  the  other  instances  I 
could  not  trace  its  history  to  any  predisposing  cause. 
The  fii'st-case  of  this  anomalous  growth  that  I  ever  saw 
was  in  the  Woman's  Hospital,  in  1856,  in  a  young  Irish 
girl,  who  had  painful  menstruation  as  the  consequence 
of  a  curved  contracted  cervical  canal.  Dr.  Emmet  and 
myself  called  it  the  cock's-comb  excrescence.  We  called 
it  this  merely  to  give  it  a  name.  The  name  was  sug- 
gested by  the  form  of  the  growth,  by  its  mobility,  by 
its  gristly  feel,  and  by  the  manner  of  its  attachment. 

It  has  a  sessile  attachment  to  the  neck  of  the  womb, 
perhaps  half  an  inch  wide  above,  growing  narrower  as 
it  descends.  It  can  be  diagnosed  with  the  greatest  faci- 
lity by  the  bi-manual  method  of  palpation.  Indeed  I 
never  consider  any  obscure  condition  of  the  uterus 
thoroughly  made  out  till  we  manipulate  the  whole 
surface  of  the  organ  almost  as  completely  as  if  we  had 
it  outside  of  the  body.  This  affection  is  not  described 
in  the  books,  but  I  have  no  doubt  that  others  will  find 
it  where  they  have  not,  as  yet,  suspected  anything  of 
the  sort ;  and  the  professional  mind  once  directed  towards 
it,  I  have  as  little  doubt  that  some  one  will  be  able, 
some  time  or  other,  to  give  us  its  pathological  appear- 
ances from  post-obit  examinations. 


238  UTERINE  SURGERY. 

But  to  return  to  anteversions.  We  may  have  tliem 
from  other  causes.  We  often  see  granular  engorgement 
of  the  anterior  lip,  accompanied  by  a  corresponding 
engorgement,  or  hypertrophy  of  the  anterior  wall  of  the 
uterus.  And  here  th'^re  is  always  anteversion.  Some 
think  that  these  corresponding  conditions  of  the  cervix 
and  body  anteriorly  are  pathologically  one  and  the  same 
thing ;  but  we  often  see  the  engorged  condition  of  the 
OS  and  cervix  cured  without  the  least  impression  being 
produced,  either  on  the  hypertrophy  of  the  anterior  wall 
or  on  the  relative  position  of  the  fundus. 

We  sometimes  have  the  uterus  bound  down  by  liga- 
mentous adhesions,  the  result,  most  j^robably,  of  some 
former  peritoneal  inflammation.  These  cases  are  com- 
paratively rare ;  but  that  they  do  exist  is  proved  both  by 
observation  on  the  living,  and  by  post-mortem  examina- 
tion. We  more  frequently  find  ligamentous  adhesions 
in  retroversions  thni  in  anteversions. 

Of  course  we  can  do  nothins:  for  the  rectification  of 
malpositions  dependent  upon  adhesions,  nor  as  a  rule 
will  they  require  any  interference,  for  the  adhesions 
naturally  sustain  and  support  the  uterus  in  its  abnormal 
relations,  and  protect  it  against  the  pressure  of  the  super- 
incumbent viscera,  which  would  otherwise  force  it  still 
lower  in  the  cavity  of  the  pelvis.  In  those  cases  in  which 
I  have  found  the  uterus  bound  down  by  adhesions,  there 
was  little  or  no  complaint  of  the  symptoms  ordinarily 
attendant  upon  such  displacement. 

So  far  as  the  treatment  of  the  sterile  condition  in 
connection  with  anteversion  is  concerned,  I  fear  that  our 
efforts  must  be  confined  almost  wholly  to  seeing  that  the 
OS  tincae  is  open  enough,  that  the  cervix  is  of  proper  form 
and  size,  and  that  the  secretions  of  the  vagina  and  of  the 
cervix  are  suited  to  the  viability  of  the  spermatozoa. 


UTERINE  UISPLACEMENTS. 


239 


The  introduction  of  the  uterine  sound  by  Simpson 
constitutes  an  era  in  obstetric  surgery.  Before  this  we 
knew  as  little  about  the  rectification  of  displacements 
as  we  did  about  their  diagnosis.  It  was,  and  is  still,  used 
as  a  redress€r  of  displacements,  in  retroversions,  with 
much  show  of  science  and  precision,  if  not  of  skill  and 
success ;  but  in  anteversions  with  none  of  these.  As  a 
mere  probe,  it  is,  as  I  have  said  before,  very  valuable, 
although  the  practised  touch  seldom  needs  its  aid  ;  but 
as  a  redresser,  it  is  capable  of  doing  great  mischief,  and 
should  no  longer  be  used  as  such.  Even  as  a  probe, 
merely  to  determine  the  course,  curvature,  and  exact 
depth  of  the  uterine  cavity,  it  is 
possible  to  do  harm  with  it. 

In  anteversion  I  now  seldom  ever 
use  it  in  the  dorsal  decubitus ;  but 
place  the  patient  in  the  left  lateral 
semiprone  position,  as  for  all  uterine 
operations.  When  the  cervix  is 
brought  into  view,  it  is  pulled  gently 
forwards  by  a  small  tenaculum  (figs. 
14  and  53),  and  then  the  annealed 
probe  (fig.  40),  more  or  less  curved 
to  suit  the  previously  ascertained  or 
suspected  curvature  of  the  canal,  is 
to  be  introduced  with  great  gentle- 
ness. As  soon  as  it  passes  the  os 
internum,  it  goes  to  the  fundus  al- 
most by  its  own  weight,  simply  by 
elevating  the  handle  of  the  instru- 
ment towards  the  sacrum.  We  can 
never  do  harm  or  even  produce  pain,  if  we  adapt  the  size 
nnd  curvature  of  the  probe  to  the  peculiarities  of  the 
individual  case.     We  may  occasionally   need   one    not 


FlQ.  93. 


240  UTERINE  SURGERY. 

larger  than  that  shown  in  fig.  93,  and  we  sometimes  need 
to  carve  it  quite  as  much  iu  complete  anteflexions,  such 
as  are  represented  in  figs.  41  and  60. 

Putting  the  cervix  on  the  stretch  by  means  of  the 
tenaculum  hooked  into  the  anterior  lip  of  the  os  greatly 
facilitates  the  use  of  the  probe  in  difficult  cases,  by 
fixing  the  uterus  and  by  straightening  the  curvature 
of  the  canal.  I  am  sure  that  much  harm  has  been 
done  with  the  sound;  1st,  by  having  it  too  large;  2nd, by 
having  it  too  straight,  or  always  fixed  at  the  same  curva- 
ture, as  shown  in  fig.  39 ;  and  3rd,  by  using  too  much 
force.  Again  let  me  repeat  that  we  are  never  to  forget 
that  it  is  simply  a  probe,  and  that  we  are  to  handle  it  as 
delicately  as  we  would  a  probe  for  any  other  surgical 
purpose. 

While  we  then  accept  the  sound  as  a  probe,  we  must 
wholly  reject  it  as  a  redresser.  For  diagnosis  it  is 
valuable ;  for  treatment  it  is  dangerous.  During  the 
learned  discussion  in  the  French  Academy  of  Medicine 
a  few  years  ago,  on  the  uses  and  abuses  of  this  instru- 
ment, the  fact  was  fully  established,  that  it  had,  per- 
haps more  than  once,  been  forced  through  the  fundus 
uteri,  and  that  death  was  the  consequence  of  this  rude 
and  awkward  accident.  This  could  only  have  happened 
by  using  it  with  violence  as  a  redresser.  There  is  some 
show  of  philosophy  to  justify  ics  use  in  retroversion,  but 
why  it  should  ever  have  been  used  to  replace  an  ante- 
verted  uterus  I  cannot  understand ;  and  yet  I  have  seen 
patients  with  anteversion,  who  had  for  months  been 
subjected  to  the  introduction  of  the  sound  almost  daily; 
I  need  hardly  add,  without  the  least  benefit. 

To  replace  in  this  way,  or  in  any  other,  an  anteverted 
uterus  with  the  expectation  of  its  remaining  in  a  normal 
position  by  this  means  alone,  is  perfectly  futile ;  for  it 


UTERIXE  DISPLACEMENTS.  241 

invariably  Mis  back  into  its  abnormal  position  the 
very  moment  that  the  force  is  removed  that  replaced  it. 

For  the  replacement  of  an  anteverted  uterus  we 
need  no  instrument  whatever.  The  process  is  simple 
enough,  and  is  effected  easier  and  better  by  mere 
manipulation  than  by  any  instrumental  aid.  The 
bladder  empty,  the  patient  on  the  back,  introduce  the 
left  index  finger,  as  shown  in  fig.  1,  to  the  anterior 
cul-de-sac ;  make  pressure  outwardly  with  the  other 
hand,  to  be  sure  that  the  uterus  is  anteverted ;  then 
remove  the  outer  pressure,  and  with  the  index  finger 
still  resting  a  little  anterior  to  the  cervix,  elevate  the 
OS  tincse  in  the  direction  of  the  pubes,  by  carrying  the 
anterior  wall  of  the  vagina  on  the  point  of  the  index 
finger  up  behind  its  inner  face  ; — this  ]3i'essure  bringing 
the  cervix  forwards  and  upwards,  necessarily  elevates 
the  fundus  from  its  bed  behind  the  pubes  and  throws 
it  slightly  upwards ; — now  push  the  ends  of  the  fingers 
of  the  right  hand  on  the  outside  from  above,  down 
into  the  hypogastrium  closely  behind  the  pubes,  so 
that  the  fins^ers  of  the  two  hands  shall  feel  that  there 
is  nothing  between  them  but  the  thin  walls  of  the 
abdomen  and  the  thinner  walls  of  the  vagina  and 
bladder.  While  the  right  hand  is  thus  held  firmly, 
the  fingers  occupying,  as  it  were,  the  place  just  filled 
by  the  fundus  uteri,  quickly  slide  the  left  index  from 
the  anterior  to  the  posterior  cul-de-sac  of  the  vagina, 
and  push  this  before  it  till  the  finger  lies  snugly  up 
behind  the  cervix  uteri ;  then  elevate  it,  as  it  v/ere, 
against  the  points  of  the  fingers  of  the  i-ight  hand,  with 
which  push  back  the  fundus,  and  retrovert  the  whole 
organ  while  we  hold  it  up  almost  in  contact  with  the 
abdominal  parietes. 

Thus  we  are  able  not  only  to  straighten    up  the 

16 


242  UTERINE    SURaERY. 

organ,  but  to  manipulate  every  portion  of  tbe  external 
surface  of  the  uterus :  the  fundus  and  body,  before  we 
attempt  to  replace  it  (fig.  1) ;  the  remainder  by  the 
above  manceuvre. 

--  This  is  ordinarily  easily  done,  even  in  very  fat  woman, 
because  nature  provides  a  sulcus  between  the  fatty 
deposit  in  tbe  walls  of  the  abdomen,  and  the  pubic 
covering  in  whicli  the  outer  hand  is  readily  carried 
down  behind  the  pubes  as  above  directed. 

We  only  find  trouble  in  delicate,  nervous,  hysterical 
women,  where  there  is  involuntary  spasm  of  the  abdo- 
minal walls,  or  where  the  cervix  uteri  is  firmly  held 
back  by  shortened  utero-sacral  ligaments. 

It  is  by  thus  passing  the  left  index  finger  behind  the 
cervix  uteri,  and  then  drawing  the  whole  organ  directly 
forwards,  almost  against  the  inner  face  of  the  pubes,  and 
pushing  the  ends  of  the  fingers  of  the  outer  hand  down 
behind  the  uterus  instead  of  before  it,  that  we  can  dia- 
gnose with  the  greatest  accuracy  fibroid  tumours,  whether 
sessile  or  pedunculated,  and  such  oflPshoots  as  are  repre- 
sented in  fig.  92,  page  236.  It  was  but  the  other  day 
that  a  friend  of  great  eminence  in  the  profession  asked 
my  opinion  in  reference  to  a  fibroid  suspected  to  be  in 
the  posterior  wall  of  the  uterus.  He  was  hesitating 
whether  to  attack  it  through  the  cavity  of  the  uterus  or 
thiough  the  cul-de-sac  of  the  vagina.  By  this  bi-manual 
mc'jhod  of  palpation  alone,  I  was  able  in  a  moment  to 
say  that  the  tumour,  nearly  as  large  as  the  foetal  head  at 
term,  was  pedunculated,  and  that  the  pedicle,  about  an 
inch  long  and  three-fourths  of  an  inch  thick,  was  attached 
to  the  posterior  face  of  the  uterus,  about  half-way 
between  the  insertion  of  the  vagina  and  the  fundus 
uteri  (fig.  94).  It  is  not  necessary  to  say  more  about 
the  peculiarities  of  the  case  here,  except  that  in  the 


UTERINE    DISPLACEMENTS. 


243 


course  of  a  few  minutes   my  friend  was  perfectly  con- 
vinced of  the  exactness  of  the  diagnosis. 

But  to  return  to  the  subject  of  ante  version.     So  far 
as  the  mechanical  treatment  of  an te version  ^er  se  is  con- 


FiG.  94. 


cerned,  I  know  of  but  one  instrument  that  has  the  power 
of  rectifying  the  position  perfectly  and  at  once,  and  that 
is  the  iiitra-uterine  stem  (with  disk)  of  Dr.  Simpson. 
But  unfortunately  the  risks  of  the  instrument  are  too 
great ;  and  I  know  but  three  practitioners  in  my  own 
country  who  have  not,  after  repeated  trials,  discarded  it 
altogether.  These  ore  Professor  Peaslee  and  Professor 
Conant,  of  New  York  City,  and  Professor  Mack,  of 
Buffalo. 

In  the  practice  of  the  Woman's  Hospital,  Dr.  Emmet 
and  myself  were  long  ago  compelled  to  discontinue  its 
use,  on  account  of  frequent  accidents,  such  as  h.'emor- 
rhage,  metritis,  and  pelvic  cellulitis.  Sometimes  a  small 
Meigs's  gutta-percha  ring  will  afford  relief,  not  so  much 
by  I'ectifying  the  position  as  by  elevating  the  organ 
slightly  in  the  pelvis,  and  taking  some  of  its  weight 
from  the  bladder.  Sometimes  we  derive  considerable 
comfort  from  a  small  globe  pessary,  particularly  if  it  can 
be  made  to  rest  just  anterior  to  the  cervix  uteri.     For 


244  UTERINE  SURGERY 

this  purpose  1  have  now  and  then  attached  a  stem  to 
the  globe,  which  projects  externally,  and  is  curved  ap 
over  the  pubes,  to  prevent  the  ball  from  running  down 
into  the  posterior  cul-de-sac. 

Fig.  95  will  represent  a  very  common  form  of  ante- 
version.  Now,  if  we  introduce  a  globe  pessary  an  inch 
and  a  quarter  in  diameter,  it  will  ordinarily  pass  to  the 
very  bottom  of  the  vagina  at  «,  resting  there  under  the 
cervix,  and  elevating  it,  while  the  fundus  will  be  thereby 
rather  depressed  anteriorly  than  otherwise ;  thus  aggra- 
vating the  malposition :  but  if  we  attach  a  malleable  stem 
to  the  globe,  and  curve  it  externally  at 
the  proper  length  to  prevent  it  from 
passing  further  than  the  anterior  cul- 
de-sac,  its  tendency  is  to  throw  the 
fundus  upwards  in  a  normal  direction 
\,^  1    by  its  pressure  or  traction  on  the  an- 

Pj^  95  terior  wall  of   the  vagina  at   h.     Its 

action  is  readily  understood  by  press- 
ing the  index  finger  forcibly  up  behind  the  symphysis 
pubis,  which  easily  elevates  the  anteverted  uterus.  If 
the  ball  be  too  large,  its  pressure  here  will  retro  vert  the 
uterus,  just  as  a  tumour  growing  low  down  on  the  cervix 
anteriorly  will  throw  the  fundus  l)ackwards. 

But  all  instruments  with  external  projections  annoy 
and  irritate  a  naturally  sensitive  nervous  system,  already 
rendered  more  irritable  by  disease,  and  are  to  be  avoid- 
ed if  possible.  I 

It  was  the  fashion  a  short  time  ago  to  use  a  sponge, 
with  a  string  for  its  removal.  To  this  practice  there 
are  two  serious  objections:  1st,  nothing  could  be  more 
disgusting  than  a  sponge  thus  worn  for  six  or  eight 
hours ;  and  2nd,  the  sponge  always  swells  considerably 
by  absorbing  moisture,  and  soon  patients  feel  the  need 


UTERINE  DISPLACEMENTS.  245 

of  increasing  its  size,  and  they  generally  get  to  intro- 
ducing two  instead  of  one.  The  patient  that  once  con- 
tracts the  habit  of  wearing  a  sponge  in  the  vagina  will 
find  it  very  difficult  to  break  it  up. 

But  what  is  better  than  th^  and,  indeed,  better  than 
almost  anything  of  the  sort,  is  thp  application  of  a  small 
wad  of  cotton,  not  more  than  an  inch  in  diameter  when 
moderately  compressed,  which  may  be  used  simple  or 
moistened  with  glycerine,  or  otherwise  medicated.  In- 
stead of  expanding,  it  gets  smaller  by  the  pressure  of 
the  parts.  A  pessary  of  simple  cotton  should  never 
be  retained  more  than  twenty-four  hours  :  moistened 
with  glycerine,  it  may  be  w^orn  tw^o  or  three  days,  or 
till  it  come  away  spontaneously.  The  cotton  pessary 
secured  with  a  string  for  its  removal,  is  to  be  applied 
by  means  of  a  porte-tampon,  described  and  figured  fur- 
ther on. 

In  very  aggravated  cases  of  anteversion,  where  the 
whole  organ  lies  flatly  down  on  the  anterior  w^all  of  the 
vagina  and  parallel  with  it,  we  often,  indeed  almost 
always,  find  the  vagina  unusually  deep,  with  the  ante- 
rior wall  greatly  elongated.  For  such  cases  I  devised 
and  executed  an  operation  in  1857,  which  has  answered 
a  most  admirable  purpose. 

It  was  under  these  circumstances.  A  lady  was  sent 
to  me  by  Professor  Josiali  C.  Nott,  of  Mobile,  Alabama, 
in  December,  1856,  who  had  a  most  complete  antever- 
sion, the  fundus  uteri  being  draw^n  dow^n  behind  the 
inner  face  of  the  pubic  symphysis  by  a  fibroid  tumour 
on  the  fundus  anteriorly.  Fig.  96  represents  the  rela- 
tive position  of  the  uterus  and  tumour  a.  I  have  never 
seen  a  more  complete  anteversion.  The  diagram  does 
not  in  any  way  exaggerate  any  of  the  details  of  the  case. 
She  had  a  cervical  leucorrhosa,  which  was  cured  in  a 


246 


UTERINE    SURGERT. 


few  weeks ;  but  the  cystorrhoea,  vesical  tenesmus,  and 
malposition,  with  its  other  inconveniences,  persisted. 
For  the  relief  of  the  displacement  I  tried  all  sorts  of 
pessaries,  but  nothing  did  any  good.     The  pelvis  was 


Fig.  96. 


deep,  the  vagina  capacious,  the  anterior  wall  unusually 

long,  and  the  uterus  laid  down  on  and  parallel  with  it. 

I  discovered  that  the  malposition  could  be  entirely 

rectified   by  hooking  a  tenaculum  in   the  anterior  lip 


Fig.  97. 


of  the  OS  tincse,  and  drawing  the  cervix  down  towards 
the  urethra.  By  continuing  this  traction  till  the  cervix 
was  brought  forward  about  an  inch  and  a  half,  the  fundus 
rose  up  in  the  pelvis  into  rather  a  noi-mal  j^osition,  not- 


UTERINE    DISPLACEMENTS. 


247 


withstanding  the  weight  of  the  tumour  on  its  anterior 
portion.  When  the  os  tincse  was  thus  drawn  forwards, 
the  elono^ated,  relaxed  anterior  wall  of  the  vat2^ina  was 
naturally  folded  upon  itself,  presenting  the  appearance 
of  an  enormous  anterior  cul-de-sac,  as  at  c/,  fig.  97. 

Under  these  circumstances,  could  anything  have  been 
more  positively  indicated  than  an  operation,  to  retain 
the  uterus  in  the  position  in  which  it  was  thus  held  by 
the  tenaculum  ? 

The  operation  of  shortening  the  elongated  anterior 
wall  of  the  vagina,  by  attaching  the  cervix  uteri  to  it  at 
the  point  <?,  was  therefore  most  naturally  a  self-suggested 
affair.  It  was  very  simi)le,  and  as  a  mere  operation 
must  always  be  a  successful  one ;  whether  it  will,  when 
successful,  always  produce  relief  of  suffering,  time  and 
further  experience  can  alone  determine. 

Two  semilunar  surfaces  a  half-inch  wide,  and  running 
nearly  across  the  anterior  wall 
of  the  vagina,  the  one  in  jux- 
taposition with  the  cervix,  and 
the  other  an  inch  and  a  half 
or  more  anterior  to  it,  were 
carefully  denuded  of  the  va- 
ginal mucous  membrane,  as 
shown  in  iig.  98.  They  were 
then  closely  united  by  seven 
silver  sutures,  as  in  the  opera- 
tion for  vesico-vaginal  fistula. 
The  patient  was  put  to  bed, 
and  a  self-retainins:  catheter 
worn  for  a  few  days ;  after 
which  the  urine  was  drawn  off 
when  necessary.  At  the  end  of  ten  or  twelve  days 
the  sutures  were  removed,  the  union  of    the  two  sur- 


PlU.  DS. 


248  UTERINE    SURGERY. 

faces  "being  perfect.  The  patient  retained  the  recum- 
bent posture  for  a  week  loiiger,  to  allow  the  cicatrix 
to  get  strong  enough  to  resist  any  traction  that  might 
be  made  by  the  bladder,  rectum,  or  uterus  itself. 

The  uterus  was  held  as  nicely  in  its  proper  position 
by  this  bridle  of  vaginal  tissue  as  it  was  previously  by 
the  tenaculum  ;  and  fortunately  she  was  wholly  relieved 
of  the  suffering  symptoms,  of  which  she  had  so  long 
complained  before  the  operation. 

Twelve  months  afterwards  this  lady  gave  birth  to  a 
son.  I  saw  her  husband  a  year  aftei*  the  birth  of  the 
child,  and  he  reported  his  wife  as  enjoying  most 
excellent  health,  never  having  felt  the  slightest  symp- 
toms of  her  old  troubles  at  any  time  since  the  operation. 
I  am  sorry  to  say  I  have  perfcjrmed  this  operation  in 
but  two  other  instances.  I  have  seen  many  cases  suita- 
ble for  it,  but  they  have  been  satisfied  to  put  up  with 
some  clumsy  mechanical  contrivance  rather  than  submit 
to  an  operation.  As  I  have  not  seen  the  case  above 
related  since  the  confinement,  I  cannot  say  what  effect 
the  labour  produced  on  the  cicatrix,  but  I  should  expect 
to  find  it  intact. 

In  1859,  a  young  lady  aged  twenty-six  was  sent  to 
the  Woman's  Hospital  with  just  such  an  ante  version 
as  the  one  above  related,  except  that  the  fibroid  on  the 
fundus  of  the  uterus  was  much  larger.  She  was  a 
patient  off  and  on  for  twelve  months,  and  Dr.  Emmet 
and  myself  exhausted  all  our  mechanical  ingenuity  (and 
patience  too)  without  producing  the  least  benefit. 

At  last  I  pro]30sed  to  her  the  operation  above 
described,  tellins^  her  at  the  same  time  that  it  had  been 
done  but  once  before.  She  readily  accepted  it;  and 
the  operation  was  pei formed  in  May,  1860,  with  perfect 
success,  and   with  almost  entire  relief  to  all  her  suffer- 


UTERINE  DISPLACEMENTS.  249 

ini^s.  I  have  seen  this  young  lady  repeatedly  since; 
the  lust  time  in  July,  1862,  being  then  twenty-six 
montlis  after  the  operation,  and  the  uterus  remained  just 
as  it  was  when  she  first  left  the  Hospital. 

I  performed  this  operation  a  third  time  in  1860,  at 
the  Woman's  Hospital ;  the  patient  left  soon  after- 
wards, and  as  I  have  not  seen  or  heard  from  her  since, 
I  cannot  say  what  was  its  effect  upon  her  health ;  but 
the  operation,  as  such,  was  as  successful  in  every 
particular  as  in  the  other  two  instances. 

I  would  not  be  understood  as  recommendinsr  this 
operation  as  a  universal  one  in  anteversion.  It  is  to  be 
resorted  to  only  when  the  anterior  wall  of  the  vagina  is 
unusually  long,  and  when  the  uterus  lies  down  parallel 
with  it,  presenting  the  fundus  just  behind  the  inner  face 
of  the  symphysis  pubis. 

Of  Retroversion. — While  the  table  on  page  231 
shows  that  about  one-third  of  all  sterile  women  have 
anteversion  from  some  cause  or  other,  it  also  shows  that 
another  third  suffer  from  retroversion ;  although  these 
two  forms  of  displacement  vary  in  the  two  classes  of 
natural  and  acquired  sterility ;  the  ante  versions,  as 
before  stated,  predominating  in  the  first,  and  the  retro- 
versions in  the  second. 

The  uterus  is  retroverted  when  the  fimdus  falls 
backwards  under  the  promontory  of  the  sacrum  or 
whenever  it  passes  an  angle  of  45°  in  that  direction 
from  its  noi'mal  position.  But,  as  before  said,  it  never 
stops  at  45®,  seldom  at  90*^,  and  often  goes  to  135°. 
Thus  we  may  have  different  degrees  of  this  version. 
We  can  ordinarily  diagnose  a  reti'oversion  by  the 
bi-manual  method  of  palpation,  already  more  than  once 
tlescribed ;    but  if  at  any  time  we  are  in  doubt,  the 


250 


UTERINE   SURGERY. 


uterine  probe  will  easily,  and  with  great  certainty, 
settle  the  point.  If  we  find  a  tumour  in  the  retro 
uterine  region,  and  doubt  whether  it  be  the  fundus  of 
the  uterus  or  not ;  and  if  we  can  pass  the  probe  into 
it  to  the  depth  of  two  inches  and  a  half,  then  it  is  the 
fundus ;  but  if  it  pass  two  inches  and  a  half  or  more 
in  some  other  direction,  then  it  is  not  the  fundus. 
There  is  no  need  of  our  ever  beins:  in  doubt  as  to 
a  retroversion.  The  physical  signs  elicited  by  the  touch 
and  the  probe  are  invariable  and  indubitable.  I  have 
already  said  so  much  on  these  two  methods  of  diagnosis, 
that  more  is  here  unnecessary. 


Pig.  99. 


Fig.  89,  page  228,  represents  the  uterus  in  a  normal 
position.  Fig.  99  represents  the  uterus  i-etroverted  from 
its  normal  position  a  to  an  angle  of  at  least  90°.  In 
retroversions  like  this  there  is  ordinarily  a  gi'eater  degree 
of  vesical    tenesmus    than    in    ante  versions.      This    is 


UTERINE  DISPLACEMENTS.  251 

explained  by  the  fact  tliat  in  tlie  one  the  neck  of  the 
bladder  is  the  seat  of  pressure,  while  it  is  the  fundus  in 
the  other.  The  diagram  represents  the  manner  in  which 
the  neck  of  the  bladder  may  be  jammed  against  the 
symphysis  'pubis  if  the  uterus  is  much  hypertrophied. 
Here  it  is  not  relatively  augmented  in  its  long  diameter. 
It  also  shows  how  awkwardly  the  fundus  of  the  bladder 
is  pulled  back  by  its  attachment  to  the  cervix  uteri,  and 
how  the  cervix  occupies  the  place,  as  it  were,  of  the 
has  fond  of  the  bladder. 

It  is  possible  in  many  instances  to  replace  a  i^etro- 
verted  uterus  by  manipulation  alone,  simply  by  pushing 
the  cervix  back  with  the  index  finger  till  the  os  looks  in 
the  direction  of  the  hollow  of  the  sacrum,  and  as  the 
fundus  rolls  upwards,  grasping  it  with  the  outer  hand 
through  the  walls  of  the  abdomen  and  pulling  it  for- 
wards. We  can  thus  often  produce  a  complete  ante- 
version  of  the  organ.  But  it  is  not  always  easy  to  do 
this,  particularly  if  the  pelvis  is  deep,  the  uterus  large, 
the  vagina  long,  and  the  patient  fat.  It  is  then  neces- 
sary to  resort  to  instrumental  aid,  the  simplest  of  which 
are  two  or  three  sponge  probangs,  with  sponges  not 
larger  than  the  ball  of  the  thumb. 

For  this  purpose  place  the  patient  on  the  left  side, 
as  for  all  uterine  opei-ations,  introduce  the  speculum, 
push  one  of  the  sponge  probangs  gently,  firmly,  forcibly 
into  the  posterior  cul-de-sac,  holding  it  there  steadily  till 
the  cervix  uteri  is  raised  from  its  contact  with  the  ante- 
rior wall  of  the  vagina;  then  place  the  other  sponge 
against  the  cervix  anteriorly,  and  gently  push  it  back 
towards  the  posterior  cul-de  sac,  at  the  same  time  that 
the  pressure  is  continued  by  the  first  one.  This  will 
generally  roll  the  fundus  over  forwards,  and  elevate  it 
from  its  bed  in  the  utero-rectal  pouch. 


252  UTERINE  SURaERT. 

Thus  let  fig.  99  represent  a  retroverted  uterus  witb 
the  speculum  and  the  first  sponge  probang  in  situ.  The 
pressure  with  the  probang  mu^t  be  made  in  the  direction 
of  the  dotted  line  h  under  the  fundus  uteri,  directly 
towards  the  hollow  of  the  sacrum,  or  in  other  words,  in 
the  direction  of  the  proper  axis  of  the  vagina.  The 
tendency  of  this  is  at  once  to  throw  the  fundus  upwards, 
by  tilting  the  cervix  downwards  and  backwards.  When 
this  has  been  carried  as  far  as  possible,  then  the  pressure 
of  the  second  sponge  against  the  anterior  face  of  the 
cervix  completes  the  rectification  of  the  malposition, — 
provided  we  are  careful  to  make  the  pressure  in  the 
right  direction.  If  the  handle  of  the  sponge  probang 
be  carried  far  back  towards  the  perineum  or  the  blade 
of  the  speculum,  in  the  direction  of  the  dotted  line  c,  it 
will  strike  against  the  cervix  uteri  or  in  the  anterior  cul- 
de-sac,  and  of  necessity  retrovert  the  uterus  to  a  greater 
degree,  by  pushing  the  cervix  upwards  and  forwards 
instead  of  downwards  and  backwards.  But  if  the  handle 
of  the  probang  be  kept  close  to  the  urethra,  the  pressure 
will  be  made  in  the  direction  of  the  line  ^,  which  neces- 
sarily causes  the  uterus  to  revolve  on  its  own  axis,  the 
cervix  taking  the  relative  position  just  occupied  by  the 
fundus,  while  this  rises  up  above  the  promontory  of  the 
sacrum.  We  shall  generally,  but  not  always,  succeed  in 
this  simple  way  in  restoring  the  uterus  to  its  proper 
position. 

If  we  produce  any  pain  by  this  process,  it  will  be 
in  consequence  of  pressure  against  the  hypertrophied 
tender  posterior  wall  of  the  uterus,  or  against  a  pro- 
lapsed supersensitive  ovary,  or  something  else  abnormal, 
in  the  Douglas  cul-de-sac,  all  of  which  it  is  important 
to  ascertain  by  the  touch  before  making  efforts  at 
rej^lacement.     Then  if  we  use  two  sponge  probangs  for 


UTERINE   DISPLACEMENTS. 


253 


pressure  in  the  posterior  cul-de-sac  instead  of  one,  we 
avoid  the  production  of  pain ;  but  instead  of  pushing 
the  sponges  back  in  a  direct  line,  centrally  over  the  os 
tincse,  we  cross  them,  laying  one  on  the  left  side  of  the 
cervix,  and -the  other  on  the  right,  as  shown  in  fig.  100, 
a  h.  They  will  naturally  cross  just  over  or  very  near 
the  urethra.  I  have  had  them 
fastened  together  at  the  crossing, 
makinsr  one  automatic  machine  of 
the  two  ;  but  this  does  not  answer 
so  well,  because  we  may  sometimes 
need  to  change  the  point  of  pres- 
sure of  one  probang  and  not  of  the 
other.  We  may  not  only  need  to 
change  the  direction  of  the  force, 
but  we  may  also  wish  to  use  more 
or  less  with  one  than  the  other; 
and  we  can  do  all  this  with  greater 
facility  with  the  two  sponges  as 
they  are. 

For  instance,  suppose  we  wish 
to  change  the  pressure  of  the  pro- 
bang  a  more  to  the  left,  the  handle 
is  at  once  thrown  to  the  riii^ht  and 
it  takes  the  direction  of  the  dotted 
line  d^  and  in  like  manner  we  may 
act  with  h.  When  we  are  satisfied 
that  the  fundus  has  been  rolled  up  jfig.  loo. 

out  of  its  old  bed,  which  is  to  be 

presumed  when  the  os  tinciie  looks  directly  back  towards 
the  posterior  wall  of  the  vagina,  instead  of  towards  the 
symphysis  pubis,  then  we  are  to  apply  the  ])robang  c 
against  the  cervix,  and  ])ush  this  in  a  straight  line  back- 
wards. 


254 


UTERINE    SURGERY. 


Fig.  101  shows  tlie  uterus  somewhat  elevated  from 
its  abnormal  position,  towards  the  promontory  of  the 
sacrum.  We  may  push  the  organ  up  thus  far,  and  sup- 
pose that  we  have  reduced  the  dislocation,  because  the 


Pig.  101. 

OS  and  cervix  have  been  forced  back  into  a  normal  rela- 
tion with  the  axis  of  the  vagina.  But  the  operation  is 
not  yet  finished.  Holding  the  sponges  in  position,  the 
speculum  is  removed,  and  the  patient  requested  to  turn 
from  the  side  on  the  back ;  then  pass  the  left  index  fin- 
ger into  the  vagina,  and  place  it  against  the  anterior 
face  of  the  cervix  ;  hokl  it  firmly  there,  and  remove  the 
sponges,  one  at  a  time ;  then  while  the  cervix  is  still 
pushed  backwards  by  the  finger,  bring  the  other  hand  to 
make  the  outer  pressure  (bi-manual).  If  we  can  with 
this  grasp  the  fundus  of  the  uterus,  and  bring  it  towards 
the  symphysis  pubis,  then  we  are  sure  that  we  have  sue- 


UTERINE  DISPLACEMENTS. 


255 


ceecled  ;  if  not,  we  have  only  crowded  the  cervix  back- 
wards, flexing  it  upon  itself  and  leaving  the  fundus  in  its 
abnormal  position,  almost  as  it  was  before  (fig.  102). 


Fig.  102. 

This  is  more  apt  to  happen  when  the  pelvis  is  deep, 
and  the  supra-vaginal  portion  of  the  cervix  is  long  and 
slender.  If  our  patient  is  too  much  ftxtigiied  to  change 
her  position  to  the  dorsal  decubitus  for  the  bi-manual 
examination,  we  can  ascertain  the  degree  of  success  of 
the  effort  at  replacement  by  passing  the  uterine  sound 
while-  the  patient  is  still  on  the  left  side.  If  it  pass 
easily  the  proper  distance  in  the  direction  of  tlie  normal 
position  of  the  uterus,  then  it  is  all  right ;  but  if  it  pass 
back  towards  the  hollow  of  the  sacrum,  then  it  is  all 
wrong. 

It  is  better  not  to  fatigue  our  patient  too  much,  and 
if  we  do  not  succeed  to-day,  it  will  be  as  well  to  wait 


256 


UTERIXE  SURGERY. 


till  to-morrow.  When  we  attempt  anything  of  this 
sort,  we  must  always  be  sure  that  the  bowels  are  not 
constipated;  and  we  must  not  forget  to  have  the  blad- 
der emptied  before  trying  to  reduce  the  dislocated 
uterus. 

Fig.  103  represents  a  retro  verted  uterus  completely 


Pig.  103. 


restored  to  its  normal  position  by  the  pressure  of  two 
sponge  probangs  alone. 

"We  often  succeed  by  the  simple  process  above 
detailed;  but  suppose  we  fail  in  our  second  effort,  or 
suppose  we  are  in  doubt  about  adhesions  binding  the 
fundus  down  in  its  abnormal  position,  what  are  we  then 
to  do  ?  We  then  j^roceed  otherwise  ;  and  it  is  hei*e 
absolutely  necessary  to  use  an  intra-uterine  force. 

Dr.  Simpson  was  the  first  to  teach  us  how  to  dia- 
gnose, and  how  to  rectify  a  retroversion.  He  passes  his 
uterine  sound  to  diagnose  the  position,  and  then  turning 


UTERINE    DISPLACEMENTa 


257 


it  half  a  circle,  the  retroverted  fundus  is  necessarily- 
elevated  towards  the  promontory  of  the  sacrum.  But 
as  I  have  frequently  said  before,  this  operation  often 
produces  great  suffering,  and  sometimes  haemorrhage, 
and  I  have  pot  for  many  years  used  Simpson's  sound 
as  a  redresser.  I  have  not  seen  any  more  serious 
accident  from  it.  Some  object  to  the  instrument,  and 
ostracize  it  altogether;  because  perforation  of  the  fun- 
dus and  death  have  followed  its  injudicious  use.  This 
is  not  wise  or  logical.  I  object  to  it  only  as  a  redresser. 
Its  whole  principle  of  action  is  wrong;  and  hence  the 
pain  and  suffering  it  produces.  I  only  wonder  it  has 
not  done  greater  mischief.  Let  us  for  a  moment  look 
at  its  modus  operandi. 

Fig.  104  represents  a  retroverted  uterus  with  Simp- 


FiG.  104 

son's  sound  introduced  as  a  redresser.  Now,  if  we 
turn  the  handle  of  the  instrument  a  on  its  own  axis 
half  a  circle,  the  distal  end  will  elevate  the  uterus  from 
its  abnormal  position  to  that  shown  by  the  dotted 
figure  c;  but  in  doing  this  it  will  describe  a  semicircle 
of  but  little   less  than  two  inches   and  a  half  radius, 

17 


258 


UTERINE   SURGERY. 


sweeping  tlie  fundus  round  witli  the  whole  weight  of 
the  organ,  supported  principally  on  the  very  end  of  the 
instrument,  which  in  its  gyration  changes  its  point  of 
pressure  from  the  posterior  to  the  anterior  face  of  the 
uterine  cavity.  To  elevate  the  fundus  still  more,  we 
push  the  handle  h  back  towards  the  perineum,  which 
thrusts  the  uterine  end  upwards.  Is  it  to  be  wondered 
at,  then,  that  we  occasionally  meet  with  patients  who 
look  upon  the  uterine  sound  with  the  most  painful 
recollections  ?  Seeing  that  an  intra-uterine  force  was 
occasionally  absolutely  necessary  for  the  rectification  of 
this  malposition,  I  devised  the  following  instrument  in 


Pig.  105. 


1856,  and  have  used  it  ever  since.     Its  whole  principle 
of  action  is  that  of  elevating  the  fundus  in  a  straight 


UTERINE  DISPLACEMENTS.  259 

line  instead  of  a  circle,  and  of  supporting  the  weight 
of  the  orsran  on  a  disk  at  the  os  tincse  instead  of  the  dis- 
tal  end  of  the  instrument  at  the  fundus.  For  this  it  is 
only  necessary  to  make  a  joint  or  hinge  in  the  sound, 
about  two  inches  from  its  uterine  extremity,  and  fix  a 
disk  or  plate  there,  as  a  point  of  support  for  the  weight 
of  the  uterus.  For  instance,  let  %.  105  represent  a 
retroverted  uterus,  with  a  jointed  sound  a  introduced, 
the  joint  being  at  the  os.  Now  all  that  we  have  to  do 
with  such  an  instrument  is  to  push  the  mouth  of  the 
womb  downwards  and  backwards  into  the  posterior 
cul-de-sac  in  the  direction  of  the  place  which  was  at  the 
inception  of  this  movement  occupied  by  the  fundus.  By 
this  manoeuvre  the  os  tincse  describes  the  small  arc  of 
a  circle  represented  by  the  dotted  line  d^  while  the  fun- 
dus, being  elevated  in  a  i-ight  line,  describes  a  larger 
one,  and  takes  the  position  h;  the  handle  or  shaft  of  the 
instrument  being  I'epresented  by  the  dotted  line  c.  If 
the  instrument  be  properly  adjusted,  this  operation  is 
effected  without  suffering  to  the  patient  or  injury  to  the 
uterus.  If  there  are  adhesions,  we  can  measure  very 
accurately  their  resistance  and  extensibility.  I  now 
remember  two  cases  in  which  from  this  cause  it  was 
impossible  to  elevate  the  uterus  more  than  45°  above 
the  axis  of  the  vagina. 

Fig.  106  represents  the  uterine  elevator  with  the 
uterine  stem  a  set  at  an  angle  of  45^^,  being  the  proper 
angle  for  an  ordinary  i*etroversion  :  c  is  the  ball  or  disk 
for  the  support  of  the  weight  of  the  uterus.  It  revolves 
on  its  own  axis  in  a  line  with  the  shaft,  permitting 
the  stem  a  to  describe  a  whole  circle,  except  UO*^, — 45^ 
on  each  side  of  the  shaft.  This  ball  is  perforated 
with  seven  Imles  (the  stem  occupying  the  eighth),  made 
in  a  line  arouad  its  centre,  for  the  reception  of  a  pointed 


260 


UTERINE    SURGERY. 


rod,  concealed  in  the  tubular  shaft,  which  is  pulled 
down  by  the  ring  b,  and  flies 
back  aorain  when  we  let  the  riuof 
go,  so  that  the  movements  of  the 
uterine  stem  a  can  be  promptly- 
arrested  at  any  desired  point  in  its 
elevation,  simply  by  letting  go  the 
ring  B,  which,  with  the  rod,  is  driven 
up  by  a  hidden  spiral  spring  in  the 
handle  below.  The  little  perforations 
in  the  ball  are  placed  intentionally  at 
the  proper  distances  to  mark  off 
angles  of  45°  in  the  revolutions  of 
the  stem. 

This  instrument  is  simply  Simp- 
son's sound  with  a  joint  or  hinge  two 
inches  from  its  uterine  extremity  ;  but 
its  modus  operandi  is  very  different. 
One  elevates  the  uterus  in  a  risfht 
line ;  the  other  in  a  circle  totbe  right 
or  left :  one  supports  the  weight  of 
the  organ  on  a  ball  at  the  os  ;  the 
other  principally  on  the  point  of  the 
sound  in  the  uteiine  cavity  :  one 
elevates  the  uterus  by  a  power  ex- 
erted on  the  cervix ;  the  other  by 
a  like  power  on  the  fundus :  one 
seldom  produces  pain,  the  other  often 
does. 

V  This     instrument     is    sometimes 
valuable  in  assisting  us  to   diagnose 
the  relativ^e  position  of  small  tumours 
on  or  near    the    uterus.     Thus,  sup- 
pose we  have  the    uterus  impaled  with  the  stem  a  at 


Fig.  106. 


UTERINE  DISPLACEMENTS.  261 

right  angles  with  the  shaft,  its  body  being  thus  held 
firmly  in  the  centre  of  the  pelvis,  with  the  fundus 
pointing  to  the  umbilicus, — by  pulling  the  handle 
of  the  instrument  forwards  while  it  is  thus  rigidly 
fixed,  we  call  draw  the  body  of  the  uterus  towards 
and  very  near  the  inner  face  of  the  symphysis 
pubis ;  by  pushing  it  back,  we  can  carry  it  directly 
backwards  as  far  as  the  depth  of  the  vagina  and  the 
sacral  promontory  will  allow  it  to  go  ;  by  turning  the 
handle  from  side  to  side,  we  can  at  will  throw  the  fundus 
to  tlie  right  or  left,  as  we  please,  and  all  this  without 
injuiy  to  the  organ  itself,  for  its  whole  weight  is  sup- 
ported, as-  before  said,  not  on  the  point  of  the  instru- 
ment, as  when  we  execute  any  of  these  movements  with 
Simpson's  sound,  but  on  the  disk  at  the  os  tincse ;  and 
Avhile  we  are  thus  changing  the  position  of  the  uterus, 
we  can  by  a  finger  in  the  vagina  or  rectum,  and  by 
palpation  externally,  determine  whether  any  suspected 
tumour  be  attached  to  the  uterus  by  sessile  adhesions  or 
by  ligament  only,  or  whether  the  two  be  entirely  sepa- 
rate and  independent  of  each  other.  The  intra-uterine 
portion  of  the  elevator  is  malleable,  because  we  may 
sometimes  wish  to  curve  it  a  little  to  suit  the  peculiari- 
ties of  some  special  case. 

Ordinarily  this  stem  should  not  be  more  than  two 
inches  long.  It  should  never  be  long  enough  to  touch 
the  fundus  uteri  by  any  possibility.  In  its  use  we  should 
be  careful  to  keep  the  ball  or  disk  always  pressed  well 
up  against  the  os  tincse ;  for  if  it  should  slip  down  lialf 
an  inch  or  more,  we  shall  fail  to  elevate  the  fundus, 
as  the  whole  power  of  the  instrument  will  then  be 
expended  only  in  pushing  the  os  tincse  backwards  and 
doubling  the  cervix  on  itself. 

I  published  an  acount  of  this  uterine  elevator  in  the 


2(52  UTERINE   SURGERT. 

January  number  of  the  Amei^iean  Journal  of  the  Medi- 
cal Sciences  for  1858  ;  and  since  then  it  has  been  vari- 
ously modified  by  different  writers,  but  not  at  all 
improved.  Dr.  Gardner  and  Dr.  Dewees,  of  New  York, 
and  others,  have  added  a  screw  to  move  the  stem,  which 
is  objectionable,  because  it  robs  us  of  the  faculty  of 
determining  the  power  of  resistance  by  tiie  sense  of  feel- 
ing. When  we  have  a  freely  movable  joint,  as  in  this 
instrument,  it  is  easy  to  judge  of  the  weight  of  the 
uterus,  and  to  determine  the  amount  and  dei^i-ee  of 
adhesions,  when  present,  by  noting  the  exact  point  at 
which  we  feel  their  resistance. 

But  suppose  we  elevate  the  uterus,  whether  by  this 
means  or  any  other,  will  it  remain  in  its  normal  position 
simply  by  placing  it  there?  Never.  I  have  known 
physicians  to  replace  a  retroverted  uterus  day  after  day 
for  months,  but  I  never  knew  a  case  cured  by  it.  It  is 
certainly  important  in  many  cases  to  rectify  the  malposi- 
tion, but  more  than  this  remains  to  be  done  to  render  it 
permanent.  For  this  purpose  the  organ  must  be  not 
only  replaced,  but  it  must  be  retained  in  its  normal 
position  by  some  mechanical  means.  In  old  cases, 
where  the  uterus  is  tender  and  irritable,  it  will  be  well 
not  to  resort  to  a  pessary  at  once.  It  is  better  to  replace 
the  uterus  a  few  times  and  apply  simply  a  wad  of  cotton 
wet  with  glycerine,  for  the  double  purpose  of  sujDporting 
the  uterus  in  situ  for  a  while,  and  of  removing  engoi-ge- 
ment  by  the  depleting  power  of  the  glycerine  already 
described  (pp.  71,  72,  158).  Whenever  by  this  means 
or  others  we  remove  all  irritability  or  engorgement  that 
may  have  been  present,  we  must  adjust  a  pessary  of 
some  sort  to  hold  the  organ  in  its  normal  position. 

Much  has  been  written  on  the  subject  of  uterine 
displacements,  and  very  opposite  views  have  been  enter- 


UTERINE    DISPLACEMENTS.  263 

tained  of  its  treatment.  Some  look  upon  it  as  a  matter 
of  no  great  importance,  while  others  are  ready  to  at- 
tribute to  it  every  nervous  symptom  that  the  patient 
may  suffer.  Some  condemn  pessaries  and  ostracize  them 
altogether,,  while  others  advocate  them  perhaps  too  uni- 
versally. Like  most  disputed  points,  there  is  some  truth 
on  both  sides.  I  have  seen  much  harm  produced  by 
pessaries,  and  so  have  I  by  bleeding,  by  purgatives,  by 
opium,  by  quinine,  and  by  other  powerful  remedies ;  but 
I  do  not  see  why  we  should  wholly  repudiate  remedies 
or  instruments  because  they  have  been  used  injudiciously. 
I  have  also  seen  much  benefit  from  the  application  of 
the  principles  of  mechanics  to  the  treatment  of  uterine 
displacements,  but  I  am  well  aware  that  there  are  cir- 
cumstances under  which  they  are  inapplicable. 

I  have  seen  cases  in  which  Simpson's   intra-uterine 
stem  (fig.  107)  had  produced  very  serious  results,  such 
as  metro-peritonitis.     I   have   seen   Hodge's 
open  lever  pessary  (fig.  110)  dig  holes  in  the 
anterior  walls  of  the  vagina  almost  through 
into  the  bladder.     I  have  often  seen  Meigs's 
ring-pessary  (fig.  Ill)   cut  a   sulcus  in    the 
posterior  cul-de-sac  of  the  vagina  deep  enough 
to  burrow  the  finger  in.     I  have  seen  Zwang's   |2 
pessary  (fig.   108)   sever   the    urethra   from      p     in^r 
the  neck  of  the  bladder,  cutting  quite  down 
to  the  vesical  membrane,  but  not  through  it.     I  have 
known  one  case  where  the  disk  of  a  vaginal  stem-pessary 
(fig.   109)  passed  into  the    cavity  of    the  uterus,    and 
remained  incarcerated  there  for  several  days,  with  the 
cervix  closely  contracted  around   the    stem,  till  it  was 
removed  by  Professor  Lewis  A.  Sayre.  of  the  Bellevue 
Hospital  College,  New  York  ;  and  I  have  seen    Gariel's 
India-rubber  bag-pessary  inflated  till  it  distended  the 


264 


UTERINE    SURGERY. 


Fig.  108. 


vagina  so  enormously  that  it  seemed 
to  occupy  almost  the  whole  of  the 
pelvic  cavity ;  and  I  have  heard  of 
other  pessaries  producing  fistulous 
openings  into  the  rectum  and  the 
bladder.  But  notwithstanding  all 
this,  I  advocate  and  daily  use  pessa- 
ries in  some  form  or  other;  be- 
cause, if  I  did  not,  I  should  turn 
away  a  multitude  of  cases  without 
doing  anything  at  all  for  their  relief.  Pessaries  are 
necessary  evils.     We  should  always  do  without   them 

if  possible ;  but  if  it  be  im- 
possible, then  it  is  the  part  of 
wisdom  to  resort  to  such  ap- 
pliances as  will  best  answer 
the  indications  of  the  indi- 
vidual case. 

The  man  who  is  not  a  mechanic  should  never  trust 
himself  to  use  a  pessary.  Even  with  a  correct  under- 
standing of  uterine  mechanology,  we  will  often  make 
mistakes, — 

1st.  In  resorting  to  pessaries  where  there  is  metritic 
inflammation  in  some  form. 

2nd.  In  selecting  an  inappropriate  instrument. 
3rd.  In  making  it  too  large  ;    sometimes  too  small ; 
and 

4th.  In  allowing  it  to  remain  too  long  without 
removal. 

Even  if  we  feel  pretty  sure  of  the  form  of  the  instru- 
ment as  applicable  to  the  case,  it  is  difficult  for  us  to  get 
our  ideas  of  the  size  of  the  vagina  down  to  a  pi-oper 
level.  We  more  frequently  make  them  too  large  than 
too  small.     After  we  succeed  in  getting  the  pessary  to 


Fro.  109. 


UTERINE    DISPLACEMENTS.  265 

fit  accurately,  we  should  never  send  our  patient  off  till 
she  is  taught  to  remove  and  rej^lace  it  with  the  same 
facility  that  she  would  put  on  and  pull  off  an  old  slipper. 
A  pessary  is  a  thing  to  be  worn  like  a  glass  eye,  only 
when  awake.  As  a  rule,  it  should  be  pulled  off  at 
night,  and  put  on  in  the  morning,  if  needed ;  and  if 
every  poor  woman  who  is  compelled  to  use  such  an  aid 
for  the  support  of  the  uterus,  was  always  taught  to 
understand  the  principles  of  its  action,  and  to  remove 
and  replace  it  every  day  or  two,  there  would  be  none 
of  the  accidents  alluded  to  above,  to  damage  their  repu- 
tation for  usefulness.  But  the  greatest  mistake  that  we 
make  is  that  of  taking  a  single  model  and  applying  it 
universally.  What  would  be  thought  of  the  hatter  who 
expected  one  hat  to  fit  every  head  ?  Of  the  shoemaker 
who  expected  one  shoe  to  fit  every  foot  ?  Of  the  dentist 
who  expected  the  cast  of  one  alveolar  arch  to  fit  every 
other  ?  The  idea  is  most  preposterous ;  and  yet-  we 
have  been  but  little  less  wise  in  our  mechanical  treat- 
ment of  uterine  displacements. 

I  have  seen  the  inside  of  an  immense  number  of 
vaginas,  and  I  never  saw  two  that  were  in  all  particulars 
exactly  alike.  They  are  as  different  from  each  other  as 
are  our  faces  and  noses.  In  Mr.  Preterre's  (of  Paris) 
great  collection  of  palatine  fissure-casts,  numbering  now 
some  600  or  more,  each  one  has  its  peculiar  anomalies, 
and  each  its  peculiar  apparatus.  I  would  not  be  under- 
stood as  meaning  that  600  cases  of  uterine  displacement 
would  need  as  many  differently  constructed  instruments ; 
but  I  mean  this,  that  every  individual  case  is  a  study  of 
itself,  and  that  its  complications  and  peculiarities  must 
be  investigated,  understood,  and  respe/ted,  if  we  expect 
to  treat  them  snfely  and  successfully.  Bub  as  I  intend 
to  deal  here  with  pessaries  only  in  relation  with  the 


2QQ  UTERINE    SURGERY. 

sterile  conditiou,  further  general  remarks  are  uncalled 
for. 

I  do  not  pi'etend  to  say  that  a  retroverted  or  an 
ante  verted  uterus  is  incapable  of  conception  ;  but  of  this 
I  am  certain,  if  conception  occurs  when  the  uterus  is 
greatly  anteverted  or  greatly  retroverted,  it  is  rather 
accidental  than  otherwise,  and  would  have  occurred  with 
greater  fLicility  if  this  organ  had  been  in  a  normal  posi- 
tion, other  things  being  equal. 

When  we  call  to  mind  the  fact  that  of  255  cases  of 
acquired  sterility  (page  231),  111  had  retroversion 
and  61  ante  version ;  and  of  250  cases  of  natural 
sterility,  68  had  retroversion  and  103  anteversion, 
we  may  have  a  right,  as  I  have  said  before,  to  suspect 
that  the  position  of  the  uterus  is  a  matter  of  some 
importance  in  the  treatment  of  the  sterile  condition. 
Of  course  many  of  these  cases  of  malposition  were 
complicated  with  fibroids,  or  flexures,  or  engorgements, 
or  hypertrophies,  or  a  conical  cervix  in  those  who  have 
never  borne  children.  But  even  if  all  these  be  rectified, 
we  may  still  have  sterility  as  a  consequence  of  malposi- 
tion alone.  At  all  events,  the  frequency  of  malposition 
renders  it  an  important  element  in  the  treatment  of  the 
sterile  condition. 

Althouo;h  I  have  been  for  a  lono:  time  aware  of  the 
fact  that  malposition  of  the  uterus  had  much  to  do 
with  sterility,  I  never  had  the  slightest  idea  of  treating 
this  last  in  connection  with  the  malposition  till  1855 ; 
and  it  occurred  to  me  in  this  way.  I  was  consulted  in 
July,  1855,  by  a  lady  who  had  been  under  the  treat- 
ment of  Professor  Hodge,  of  Philadelphia.  The  his- 
tory of  her  case  gave  the  following  facts.  She  was 
twenty-three  .years  old,  married  at  seventeen,  in  July, 
1849;  had  a  two  months' miscarriage  in  March,  1851^ 


UTERINE   DISPLACEMENTS 


267 


from  wliicli  she  slowly  recovered,  and  was  sent  to 
Professor  Hodge  by  her  medical  attendants  in  May 
following.  He  found  the  uterus  retroverted,  and 
applied  his  pessary  immediately.  She  remained  in 
Philadelphia  seven  weeks ;  had  but  one  menstrual 
period  after  the  pessary  was  applied ;  and  returned 
home  still  wearing  it.  Her  physicians  there  pronounced 
her  pregnant,  but  did  not  remove  the  instrument  till 
September,  and  her  child  was  born  in  March  follow- 
ing. This  appeared  to  me  at  the  time  a  most  remark- 
able revelation ;  and  I  asked  this  lady  how  it  happened 
that  she  had  sexual  intercourse  while  she  woi-e  an 
instrument.  She  replied  simply,  "It  happened  so." 
"Often?"  said  I.  "Oh,  yes;  just  as  if  there  had 
been  no  instrument  there."  The  idea  of  adjusting  an 
instrument  that  would  permit  sexual  intercourse  at 
the  same  time  that  it  held  the  uterus  in  situ  was  to  me 
a  novel  one.  Since  then  I  have  acted  upon  it,  and  think 
it  of  great  importance. 

Hodge's  instrument,  as  first  invented  by  him,  is 
made  of  silver  and  then  gilt.  It  is  in  the  shape  of  the 
letter  Ui  ^^'i^^^  ^^^^-  ^^'^  inirallel  branches  curved  on  the 
flat  to  suit  the  curvatui'e  of  the  vagina. 

Fig.  110  represents  the  in- 
strument. The  cross-bar  con- 
necting the  two  bi-anches  is 
to  be  pushed  up  behind  the 
cervix  uteri  after  the  organ  is 
replaced ;  the  great  convexity 
of  the  branches  i-ests  on  the 
posterior  wall  of  the  vagina; 
and  the  open  end  looks  in  the 
direction  of  the  symphysis  pul)is ; 
while  the  extremities  of  the  branches  rest  anteriorly,  one 


Fig.  110. 


2g8  UTERI J7E    SURGERY. 

on  each  side  of  the  neck  of  the  bladder.  Theoretically 
and  practically  the  instrument  is  admirable,  when  neatly 
fitted  and  properly  managed.  Its  expensiveness  was  the 
chief  objection  to  its  general  use.  Dr.  Hodge  modified 
his  instrument  for  ante-versions,  by  placing  a  cross-bai 
on  its  front  or  open  end,  thus  closing  it  up  entirely,  and 
making  a  sort  of  sigmoid  parallelogram  of  it  (fig.  112). 
This  form  of  the  Hodge  instrument  is  commonly 
adopted  by  the  profession  in  my  own  country,  whether 
it  be  made  of  silver,  block-tin,  vulcanite,  or  gutta-percha. 
We  seldom  use  the  other  one. 

Hodge's  instrument  may  be  found  in  the  shops 
variously  modified.  For  instance,  they  are  made  of 
hard  rubber,  and  sold  in  great  quantities ;  but  these  are 
very  dangerous,  for  they  are  generally  too  large,  and 
are  fashioned  into  anything  but  the  right  shape ;  and  I 
have  found  it  impossible  to  give  them  the  proper  equi- 
lateral curvatui-es  by  heating  them  in  boiling  water  as 
is  recommended.  What  is  better  than  the  hard  rubber, 
but  not  so  cleanly,  is  a  copper  wire  covered  with  gutta- 
percha. But  even  here  we  have  a  right  to  complain  of 
all  our  instrument-makers ;  for  they  have  taken  the 
common  insulated  telegraphic  wire,  cut  it  into  slips  of 
various  leng^"hs,  and  most  clumsily  fastened  the  two 
ends  of  these  together  in  a  ring,  and  then  curved  them 
as  we  find  them.  They  do  this  to  sell  them  a  few 
pennies  cheaper.  This  is  poor  economy  ;  for  they  often 
get  fractured  where  they  have  been  joined ;  the  secre- 
tions then  enter  the  little  cracked  fissures,  and  the 
instrument  becomes  a  source  of  irritation  instead  of 
comfort.  Instead  of  this,  the  malleable  copper  wire 
should  be  first  made  neatly  into  a  ring  or  parallelogram 
and  then  smoothly  covered  with  gutta-percha,  not 
varnished.     I  have  persuaded  at  least  two  instrument- 


UTERINE    DISPLACEMENTS. 


269 


makers  (Mr.  Weiss  and  Mr.  Charri^re)  to  remedy  this 
evil.  Away  with  cheap  things !  whether  drugs  or 
instruments,  for  our  sick,  especially  for  our  sick  women ; 
and  more  especially  still  when  they  are  afflicted  with 
such  fearful  calamities  as  we  are  now  considering. 

But  my  country  holds  another  name  equally  as  hon- 
oured and  respected,  and  equally  as  authoritative  as 
that  of  Hodge,  in  advocacy  of  the  mechanical  treatment 
of  uterine  displacements.  In  1853,  Professor  Charles 
D.  Meigs  published  his  report  on  utei-ine  diseases  before 
the  American  Medical  Association,  in  which  he  promul- 
gates the  same  views  so  long  taught  by  his  illustrious 
confrere,  Professor  Hodge. 
Dr.  Meigs's  instrument  differs 
from  Hodge's,  but  its  princi- 
ple of  action  is  the  same. 
While  Hodo-e's  is  a  curved 
parallelogram,  Meigs's  is  sim- 
ply a  ring,  acting  upon  the 
same  principle  of  distending 
the  vagina  antero-posteriorly, 
by  making  the  posterior  cul- 
de-sac  and  the  inner  face  of 
the  symphysis  pubis  the  points 
of  support.  It,  too,  holds  the 
neck  of  the  womb  back  in  its 
proper  place,  and  does  not 
interfere  with  sexual  intercourse. 


Fio.  111. 


Mei 


2:ss  rinir 


pessary 

is  made  of  watch-spring,  fashioned  into  a  circle,  two, 
two  and  a  half,  two  and  three-quarters,  and  three  inches 
in   diameter,  and   then   coated   with   gutta-percha   (fio*. 

111).  _  ^ 

It  is  introduced  with  great  facility,   l)y  compi-essing 
its  opposite  sides,  thus  elongating  it  in  one  direction, 


270  UTERINE  SURGERY. 

— dotted  line  «,  while  its  diameter  in  the  other  is 
diminished.  As  soon  as  it  passes  the  arch  of  the  pubes, 
it  recovers  its  original  form,  but  seldom  ever  becomes 
perfectly  circular  again,  unless  it  is  a  very  small  instru- 
ment. If  a  large  one,  it  takes  an  oval  form  after  being 
worn  for  any  length  of  time. 

These  are  often  worn  for  a  good  while ;  but  in  a 
general  way,  as  before  stated,  I  am  opposed  to  the 
principle.  I  have  often  removed  the  Meigs  ring-pessary 
after  it  had  been  worn  continuously  for  ten  or  twelve 
months.  In  five  or  six  weeks  it  becomes  coated  with 
a  thick  layer  of  brownish  sordes,  having  a  most  dis- 
gusting smell.  This,  of  itself,  must  irritate  the  vaginal 
mucous  membrane,  independently  of  mischief  resulting 
from  prolonged  mechanical  pressure.  I  have  seen  one 
case  in  which  the  Meigs  ring  had  ulcerated  a  sulcus  in 
the  posterior  cul-de-sac  deep  enough  to  hide  the  little 
finger  in  it.  I  was  surprised  that  it  had  not  perforated 
the  peritoneal  cavity ;  but  a  close  investigation  revealed 
the  wonderfully  protective  powers  of  nature  in  throwing 
out  lymph,  and  increasing  the  thickness  of  the  tissues 
through  which  the  instrument  had  gradually  cut  its 
way.  Here  the  position  of  the  womb  had  not  been 
wholly  rectified.  The  pelvis  was  deep,  and  the  instru- 
ment had  merely  pushed  the  cervix  backwards,  while 
the  fundus  was  still  retro  verted.  Perhaps  this  was  well 
for  the  patient,  for  the  cul-de-sac  of  the  vagina  and  the 
posterior  wall  of  the  uterus  seemed  to  be  agglutinated 
firmly  together, — doubtless  the  result  cf  the  pressure 
and  ulceration  of  the  ring,  for  I  had  examined  this  case 
some  months  before  the  ring  was  applied,  and  there  was 
nothinoj  of  the  sort  then. 

I  saw  another  case  at  the  Woman's  Hospital  in  1861, 
where   a  Meigs  ring  had  been  worn  continuously  for 


UTERINE    DISPLACEMENTS.  271 

nearly  twelve  months.  At  first  it  produced  great  relief, 
but  after  a  while  there  was  an  excessive  muco-purulent 
discharge  from  the  vagina,  and  it  was  for  this  that 
advice  was  sought  at  the  Hospital. 

We  often  see  pessaries  of  this  sort  produce  mischief 
by  being  too  large,  but  here  it  was  the  contrary.  The 
cervix  and  a  portion  of  the  anterior  wall  of  the  vagina 
seem  to  have  gradually  descended  too  far  through  the 
small  rinof,  and  to  have  become  almost  strangulated. 
It  had  cut  a  deep  circular  sulcus  all  around  the  cervix, 
deeper  posteriorly  and  on  the  sides  than  anteriorly; 
and  in  this  sulcus  the  ring  was  entirely  hidden  from 
view  except  just  at  the  neck  of  the  bladder,  where  it 
was  more  superficial.  On  the  removal  of  the  instrument, 
which  was  both  difficult  and  painful,  its  bed  was  seen 
to  be  a  deep  suppurating  chasm,  with  granulating  edges 
that  had  entirely  overlapped  the  ring  behind  and  on 
the  sides.  The  cervix  uteri  was  also  very  granular,  and 
greatly  engorged,  seemingly  in  consequence  of  the  stran- 
gulating pressure  of  the  ring.  All  of  this  disappeared 
with  the  filling- up  and  healing  of  the  sulcus,  which 
occurred  in  the  course  of  a  fortnight. 

While  I  advocate,  and  daily  use  pessaries  of  some 
^ort,  it  is  but  just  that  I  should  say  all  I  know  against 
them,  simply  as  a  w^arning  of  danger  to  others.  In  this 
case  the  fault  was  with  him  who  applied  the  instrument, 
and  turned  his  poor  patient  adrift  without  giving  her 
instructions  in  its  use.  I  have  seen  more  mischief  from 
the  Meigs  ring  than  from  Hodge's  instrument.  I  pre 
sume  the  reason  is,  that  when  it  was  first  introduced  it  was 
a  cheaper  instrument  than  any  other  then  in  vogue ;  was 
therefore  more  universally  used  ;  and,  consequently,  pre- 
sented comparatively  larger  opportunities  for  observation. 
If  the  object  be  to  cure  the  sterile  state  while  we 


272 


UTERINE    SURGERY. 


treat  tlie  malposition,  I  always  use  an  instrument  on 
tlie  same  principle  as  those  above  described.  Besides 
the  Hodge  and  Meigs  instruments,  as  we  find  them  in 
the  shops  I  often  use  rings  made  of  block-tin  softened 
by  the  addition  of  a  little  lead.  These  I  introduced  in 
1856.  They  are  made  of  diiferent  sizes,  varying  from 
two  to  three  inches  in  diameter.  The  material,  if  tubu- 
lar, may  be  a  third  of  an  inch  in  diameter ;  much  less  if 
solid.  It  matters  not  whether  it  be  of  block-tin  or 
gutta-percha,  so  it  is  malleable.  Select  a  ring  to  suit 
the  capacity  of  the  vagina ;  compress  it  gently  between 
the  hands  till  it  takes  an  oval  form.  It  is  then  in  imita- 
tion of  a  Meigs  ring,  and  may  be  soused;  but  sometimes 
it  is  better  to  give  it  the  natural  curvature  of  the  vagina, 
after  Hodge's  plan,  by  making  the  distal  end  Z»,  fig.  112, 


Fig.  112. 

pass  up  behind  the  neck  of  the  womb,  wliile  the  proxi- 
mal end  a  has  a  slis^ht  counter-curvature  where  it 
presses  the  neck  of  the  bladder  against  the  symphysis 
pubis.  Great  nicety  is  necessary  in  fitting  an  instrument 
so  as  not  to  injure  by  pressure  the  neck  of  the  bladder, 
the  posterior  cul-de-sac,  or  the  floor  of  the  vagina,  upon 
which  rests  the  great  curvature.  It  will  be  diflacult  to 
get  one  instrument  with  its  exact  proportions  to  fit  any 
two  cases ;  and  it  is  often  difiicult  to  fit  any  given 
case.  It  has  frequently  taken  me  a  fortnight, 
and  sometimes  much  longer,  to    adjust  an  instrument 


UTERINE    DISPLACEMENTS. 


273 


accurately ;  and  sometimes  it  has  been  utterly  impossible 
for  me  to  do  it  at  all.  When  I  succeed  in  fitting  the 
case  exactly,  L  e.  in  supporting  the  womb  in  its  normal 
position  without  undue  pressure  on  the  vaginal  parietes, 
I  usually  send  the  model  made  of  this  malleable  mate- 
rial to  the  instrument-maker,  to  be  duplicated  in  vulca- 
nite or  silver,  if  the  patient  is  to  leave  my  care  wearing 
an  instrument.  The  block-tin  pessary  is  quite  as  good 
as  a  silver  one ;  but  then  the  patient  in  removing  and 
replacing  it  may  spoil  its  shape,  and  make  it  hurtful 
instead  of  beneficial.  If,  however,  the  patient  lives  near 
enough  for  me  to  see  her  occasionally,  I  seldom  order 
any  other  instrument  than  the  block-tin  one. 

As  I  said  before,  the  case  related  on  p.  266  gave  me 
new  views  of  practical  utility,  that  were  not  lost ;  for  a 
lady,  twenty-six  years  old,  soon  after  this  came  with  her 
husband  to  consult  me  on  account  of  her  sterility  (ac- 
quired). She  had  had  one  child  six  years  before.  It 
died  early,  and  they  were  exceedingly  anxious  for  more 
ofiBpring.  She  had  been  treated  at  different  times  by 
several  distinguished  physicians,  all  of  whom  put  her 
through  "a  course  of  caustic,"*  but  her  symptoms 
remained  the  same,  and  her  sterility  persisted.  On 
examination,  I  found  the  pelvis  deep,  the  vagina  capa- 
cious, the  perineum  relaxed,  and  the  uterus  completely 
retroverted,  but  not  difficult  to  replace.  The  posterior 
wall  was,  as  in  all  such  cases  of  prolonged  malposition, 
somewhat  hypertrophied,  and  there  was  also  some  little 
engorgement  of  the  posterior  lip.  Her  symptoms  of 
vesical  tenesmus,  bearing  down,  ifec,  were  evidently  the 
result  of  the  error  of  position,  and  I  told  them  it  was 


*  It  was  unfortunately  the  fashion  a  few  years  ago  in  my  own  country  to  cau- 
terize the  neck  of  the  womb,  without  reference  to  conditions  or  indications. 

18 


274  UTERINE    SURGERY. 

quite  impossible  for  "her  to  conceive  witli  tlie  uterus  in 
its  abnormal  position.  I  concluded  to  treat  tlie  case 
entirely  mechanically,  but  it  was  very  difficult,  for  I  did 
not  then  possess  the  tact  in  adapting  an  instrument  to 
the  peculiarities  of  the  case,  that  observation  and  enlarg- 
ed experience  can  alone  give.  It  took  me  nearly  a 
•month  to  adjust  it  so  that  it  could  be  worn  without  pain 
or  undue  pressure ;  but  once  fitted,  there  was  no  incon- 
venience from  it ;  on  the  contrary,  the  greatest  comfort. 
The  ring,  moulded  as  described,  was  fully  three  inches 
and  one-eighth  in  diameter  before  giving  it  the  form  of 
a  sigmoid  parallelogram.  A  special  injunction  was  that 
it  should  be  worn  during  sexual  intercourse.  Concep- 
tion occurred  in  three  months.  She  continued  to  wear 
the  instrument  till  after  the  third  month,  when  the 
uterus  had  risen  up  above  the  brim  of  the  pelvis,  and 
then  it  was  removed.  She  was  delivered,  at  full  term, 
of  a  fine  healthy  boy,  which  was  turned  over  to  a  wet- 
nurse.  She  was  in  hopes  that  conception  would  soon 
occur  again,  but  it  did  not ;  and  at  the  end  of  eighteen 
months  she  returned  to  ask  an  investigation  of  her  con- 
dition, and,  if  necessary  to  insure  an  early  conception, 
the  reapplication  of  the  instrument. 

I  found  the  uterus  precisely  as  it  was  when  I  first 
saw  her.  It  had  no  self-adjusting  power  whatever.  It 
could  be  replaced  with  facility,  but  dropped  back  as 
soon  as  the  finger  was  removed.  I  gave  it  as  my 
opinion  that  conception  could  hardly  occur  again  with 
the  uterus  persistently  retroverted.  I  therefore  re- 
applied the  same  instrument  with  injunctions  to  wear  it 
as  before  during  coition.  Conception  occurred  in  eight 
weeks  afterwards.  About  fifteen  months  after  the  birth 
of  the  second  child,  she  came  again,  and  I  found  the 
uterus   precisely  as   it   was   at   the   first    consultation. 


UTERINE  DISPLACEMENTS.  275 

I  adjusted  another  instrument  to  prop  it  up,  and  gave 
the  same  injunctions,  and  in  ten  months  afterwards 
she  was  again  a  mother. 

Now,  in  this  case,  I  believe  that  conception  could 
have  been'  brought  about  as  easily  five  years  sooner,  if 
the  same  treatment  had  been  adopted. 

To  establish  the  utility  of  the  pessary  during  coition, 
in  cases  of  sterility  dependent  upon  retroversion,  I 
must  continue  my  notes.  The  case  above  was  uncom- 
plicated. There  was  simple  relaxation  of  all  the  pelvic 
supports  of  the  uterus,  and  it  tilted  over  backwards, 
and  will  remain  so  always,  unless  it  be  propped  up 
mechanically.  Occasionally  a  malposition  of  this  sort 
is  cured  by  a  pregnancy,  but  often  it  is  not. 

In  1856,  a  lady  was  brought  to  the  Woman's 
Hospital,  who  had  been  bed-ridden  for  more  than  two 
years.  She  was  thirty-two  years  old ;  was  married  at 
twenty ;  gave  birth  to  a  child  in  ten  months,  but  she 
remained  sterile  afterwards.  She  became  a  widow, 
and  married  again  at  thirty.  Twelve  months  after- 
wards she  ran  hurriedly  into  the  garden  to  bring  in 
some  clothes  that  had  been  hung  out  to  dry.  On 
reaching  up  quickly,  she  felt  something  suddenly  give 
way  in  the  pelvis  ;  she  had  great  pain,  and  immediately 
went  to  bed,  suffering  also  from  nausea,  vomiting,  and 
excessive  prostration.  Her  physician  was  sent  for,  and 
attended  her  for  many  months,  but  without  much 
improvement.  I  found  the  uterus  completely  retro- 
verted,  and  greatly  enlarged,  with  the  fundus  directed 
towards  the  left  sacro-iliac  symphysis.  The  enlargement, 
or  rather  elongation  of  the  oi'gan,  was  due  to  a  fibrous 
tumour  growing  from  the  fundus,  which  explained  its 
diagonal  direction,  for  it  was  too  long  to  lie  retroverted 
in  the  median  line.     To  remove  the  fibrous  tumour  was 


276  UTERINE    SURGERY. 

out  of  tlie  question ;  to  allow  tlie  uterus  to  remain 
where  I  found  it,  was  to  consisrn  her  to  her  fate  without 
an  effort  for  her  relief.  My  only  hope  of  affording  her 
any  permanent  benefit  was  in  elevating  the  uterus, 
supporting  it  in  position,  and  giving  her  the  possibility 
of  a  conception.  When  it  was  so  elevated  into  position, 
the  tumour  could  be  distinctly  felt  on  the  fundus,  above 
the  promontory  of  the  sacrum.  But  of  course  it  would 
fall  back  into  its  old  position,  as  soon  as  the  finger  and 
the  uterine  elevator  were  removed.  By  repeating  this 
every  day  for  a  week,  the  uterus  became  sufficiently 
tolerant  of  manipulation  to  allow  the  use  of  an  intra- 
vaginal  support.  A  malleable  block-tin  ring,  about  two 
inches  and  a  half  in  diameter,  was  fashioned  into  the 
form  of  a  parallelogram,  and  curved  on  its  long  axis,  as 
already  described,  so  as  to  give  it  a  slight  sigmoid 
flexure.  The  vagina  was  rather  small,  and  great  care 
was  necessary  not  to  inflict  injury  by  undue  pressure  in 
the  posterior  cul-de-sac,  or  against  the  neck  of  the 
bladder  and  the  symphysis  pubis.  The  instrument  was 
worn  at  first  for  a  few  hours,  but  soon  it  was  worn  dur- 
ing the  whole  day,  and  after  a  short  time  she  was  able 
to  walk.  In  two  or  three  months  she  returned  home, 
not  cured  it  is  true  ;  but  the  uterus  was  elevated  into  a 
proper  position,  and  there  supported  by  the  simple 
little  contrivance  already  described.  With  the  hope 
that  conception  would  take  place,  she  was  directed  to 
wear  the  uterine  supporter  always  during  coition.  Six 
months  after  leaving  the  Hospital  she  returned  for 
observation,  and  was  found  to  be  preg*nant  four  months 
and  a  half,  having  conceived  in  six  weeks  after  return- 
ing home.  She  had  worn  the  instrument  all  the  time 
except  when  she  removed  it  for  cleaning. 

She  went  the  full  term  and  was  safely  delivered.     I 


UTERINE    DISPLACEMENTS.  ^1^1 

saw  "her  some  montlis  after  the  birth  of  her  child.  The 
uterus  was  in  its  proper  position,  but  the  tumour  was 
about  the  same.  Without  mechanical  aid  here,  I  do  not 
see  how  it  would  have  been  possible  to  have  done  any- 
thing at  all  for  this  poor  sufferer.  Thei'e  was  nothing 
whatever  attempted  for  her  but  the  replacement  of  the 
dislocated  uterus,  with  this  vaginal  splint,  as  it  w^ere,  to 
support  it  in  its  proper  relations.  This  case  might  be 
called  cured,  so  far  as  the  mere  position  of  the  womb 
was  concerned.  It  is  very  probable  that  the  fibrous 
tumour  had  existed  a  long  time  on  the  fundus,  and  that 
it  assisted  by  its  weight  when  the  uterus  was  suddenly 
retroverted  in  holding  it  down  in  its  abnormal  position, 
and  I  have  as  little  doubt  that  the  same  condition  now 
assists  in  holding  the  uterus  erect.  The  pelvis  in  this 
case  was  of  ordinary  capacity,  while  in  the  case  pre- 
viously related  it  was  very  deep,  with  a  rcxther  straight 
sacral  promontory. 

It  might  be  supposed  a  pi^iori  that  any  instrument 
in  the  vagina  would  interfere  with  coition.  I  usually 
make  it  a  rule  to  explain  the  necessity  of  the  treatment 
to  the  husband  as  well  as  the  wife.  So  far  as  our  sex  is 
concerned,  the  knowledge  of  the  presence  of  a  vaginal 
support  might  be  an  uupoetical  association ;  but  if  it  is 
properly  adjusted,  it  is  not  at  all  in  the  way.  Some- 
times the  wife  has  insisted  that  it  was  not  necessary  for 
the  husband  to  know  that  the  uterus  was  thus  artificially 
braced  up.  The  instrument  should  be  neither  too  lai-ge 
nor  too  small,  and  should  fit  snugly  up  behind  the 
symphysis  pubis. 

In  1861  I  was  consulted  by  a  young  widow,  who  had 
a  proposition  of  marriage.  Daring  her  first  marriage 
she  had  had  one  full  term  labour,  and  three  or  four  mis- 
carriages at  about  the  third  month.     Her  physicians  told 


278  UTERINE    SURGERY. 

her  that  she  would  probably  always  miscarry  at  the 
third  month.  It  was  her  opinion  that  few  men  would 
marry  if  they  did  not  expect  to  be  blessed  with  off 
spring,  and  she  herself  looked  upon  children  as  necessary 
to  the  complete  happiness  of  married  life.  With  these 
views  she  was  unwilling  to  marry  unless  she  could  have 
some  assurance  that  the  habit  of  aborting  could  be 
broken  up ;  and  upon  this  point  my  opinion  was  asked. 
I  found  the  uterus  completely  retroverted,  with  some 
enlargement  of  the  posterior  wall  from  long  error  of 
position.  I  explained  to  her  that  her  miscarriages  were 
almost  certainly  due  to  the  retroversion ;  that  conception 
would  in  all  probability  occur  with  her,  and  that  the 
pregnancy  would  go  to  its  full  term,  provided  the  uterus 
was  kept  in  its  normal  position,  till  it  got  large  enough 
to  rise  above  the  brim  of  the  pelvis.  On  this  assurance 
the  offer  of  marriage  was  accepted ;  and  in  two  months 
my  patient  was  ready  for  its  fulfilment. 

Having  adjusted  an  instrument  to  hold  the  uterus  in 
proper  position,  and  having  instructed  her  in  its  man- 
agement, the  wedding  day  was  fixed  at  the  time  she 
expected  to  finish  the  menstrual  period.  The  marriage 
took  place  early  in  January,  on  the  very  day  of  the 
cessation  of  the  flow.  The  happy  couple  immediately 
left  for  New  Orleans,  and  in  a  month  afterwards  I 
received  a  note  from  my  patient  saying  she  was  undoubt- 
edly pregnant. 

As  she  did  not  wish  to  consult  any  other  physician, 
and  as  I  was  exceedingly  anxious  for  her  to  pass  the 
third  month  without  a  miscarriage,  I  directed  her  to 
wear  the  instrument  till  she  quickened,  and  then  to 
remove  it.     At  the  full  term  she  was  safely  delivered. 

Now  here  was  a  case  in  which  the  husband  had  no 
idea  that  there  had  ever  been  any  uterine  disease  or  any 


UTERINE    DISPLACEMENTS. 


279 


mechanical  treatment,  and  does  not  know  it  to  this  day. 
The  case  is  valuable  as  showing  the  protective  power  of 
a  normal  position  against  the  dangers  of  abortion.  There 
is  no  more  common  cause  of  abortion  than  retroversion, 
if  we  except  imprudent  and  excessive  coition,  and  for 
the  simplest  of  all  reasons.  A  retroverted  womb  is 
impregnated  ;  impregnation  only  aggravates  the  mal- 
position ;  the  uterus  and  its  contents  grow  apace  till  it 
is  jammed  with  the  fundus  under  the  promontory  of  the 
sacrum,  from  which  it  has  no  natural  tendency  to  escape. 
When  it  gets  to  the  third  month,  it  must  either  rise 
above  the  brim  of  the  pelvis,  or  throw  off  its  contents. 
If  it  fail  to  do  the  one,  the  other  generally  takes  place. 
If  we  do  not  detect  the  malposition,  and  rectify  it  in 
time,  a  miscarriage  is  the  almost  inevitable  result.  I  am 
sure  I  have  often  prevented  miscarriage  by  rectifying  a 
retroverted  uterus. 

Here  is  an  example.  A  lady,  twenty-eight  years 
old,  had  had  two  labours  at  full  term.  Afterwards  she 
had  a  miscarriage  at  the  third  month.  She  subsequently 
became  pregnant,  and  at  the  end  of  two  months  and  a 
half  she  was  again  violently  threatened  with  all  the 
symptoms  of  a  speedy  miscari'iage.  I  found  the  uterus 
retroverted,  with  the  cervix  against  the  pubes,  and  the 
fundus  jammed  under  the  sacral  promontory.  The 
uterus  was  gently  replaced,  and  a  Meigs  ring  three 
inches  in  diameter  was  introduced  to  hold  it  in  its  proper 
position.  The  I'ectification  of  the  malposition  was  imme- 
diately followed  by  a  relief  of  all  uterine  symptoms. 
The  instrument  was  worn  for  a  month,  being  changed 
every  three  or  four  days.  She  went  the  full  time,  and 
was  safely  delivered.  This  case  serves  very  well  as  an 
illustration  of  a  principle,  and  as  an  example  of  its  class. 
The  cases  already  narrated  as  exhibiting  the  influence 


280 


UTERINE    SURGERY. 


of  the  pessary  in  facilitating  conception,  and,  therefore, 
in  curing  the  malposition,  were  such  as  had  conceived 
previously.  But  I  have  frequently  seen  the  same  thing 
in  the  naturally  sterile.  In  1858  Dr.  Silas  T>.  Scudder, 
then  house-physician  at  the  Woman's  Hospital,  found 
amongst  the  out-door  patients  a  woman  married  ten 
years  without  issue,  who  was  very  desirous  of  offspring. 
She  had  retroversion,  but  what  the  complications  were, 
if  any,  I  do  not  know.  However  he  fitted  a  malleable 
block-tin  ring  to  the  vagina,  and  she  conceived  in  two 
months  afterwards.  He  allowed  her  to  wear  the  instru- 
ment long  enough  to  guard  against  a  miscarriage  (three 
months),  and  she  went  the  full  term. 

In  1857  a  lady  from  the  South  consulted  me  in 
reference  to  her  sterility.  She  had  been  married  fifteen 
years  without  conceiving.  Her  beautiful  physique  and 
fine  general  health  were  all  that  could  be  desired ;  but 
she  had  painful  menstruation.  The  uterus  was  retro- 
verted,  and  she  had  a  fibrous  tumour,  as  large  as  an 
English  walnut,  in  the  j^osterior  wall,  while  the  os  was 
contracted  and  the  cervix  indurated. 

The  uterine  sound,  sponge  tent,  and  bi-manual  pal- 
pation, showed  that  the  enlargement  a  (fig.  113)  was 


Fig.  113. 


a  distinct  tumour,  and  not  a  mere  hypertrophy  of  tissue, 
as  we  so  often  see  in  old  retroversions.     The  indications 


UTERINE    DISPLACEMENTS,  281 

were  the  same  as  if  there  had  been  no  fibroid  tumour ; 
viz.,  to  enlarge  the  os  and  cervix  by  incision,  and  tlieo 
to  adjust  an   instrument   to   hold   the   uterus   in   situ 
dnrins:  coition.     From  the  contraction  of  the  os  and  the 
induration  of  the  cervix,  I  was  satisfied  that  the  case 
would  have  been  sterile  even  with  a  normal  position 
of  the  uterus.     Besides,  given  a  perfect  state  of  the  os 
and  cervix,  the  malposition  would  militate  against  the 
probabilities  of  conception.     Therefore  the  os  and  cervix 
were  divided  bilaterally  in  April,  1857.     The  ring  was 
fitted  after  the  next  menstruation  in  May,  and  in  August 
she  conceived  ;  but  unfortunately  a  fall,  three  months 
afterwards,  in  November,  produced  a  miscarriage  ;  and 
she  had  another  miscarriage  in  June,  1858,  at  about  the 
third  month.      This,  too,  was  associated  with  an  acci- 
dental fall.     It  was  accompanied  by  great  loss  of  blood, 
and  followed  by  a  serious  metritic  inflammation,  from 
which  she  did  not  recover  tor  several   weeks,   during 
which  time  she  was  carefully  attended  by  Dr.  Griscom, 
of  New  York.     As  soon  as  she  was  able  to  leave  the 
city,  we  sent  her  to  Saratoga  to  recuperate,  and  she  re- 
turned to  New  York  in  November,  her  general  health 
being  again  very  good.     It  was  now  eighteen  months 
since  we  began  to  treat  her  case.     She  had  had  two  mis- 
carriao'es,  which  we  mis^ht  have  attributed  to  the  fibroid 
tumour,  if  the  attending  circumstances   had  not  each 
time  been  sufiicient  to  have  produced  the  unfortunate 
result.     But  the  worst  feature  of  the  case  was  that  we 
were  now  precisely  where  we  started,  for  the  metritic 
inflammation  following  the  last  miscarriage   had  repro- 
duced   the  contracted   puckered   condition    of  the    os, 
which  now  looked  as  if  it  had  never  been  subjected  to  a 
surgical  operation ;  while  the  cervix  felt,  perhaps,  more 
gristly  than  before.     Wbat  was  to  be  done?     We  were 


282  UTERINE  SURaERT. 

all  ill  a  hurry  for  anotlier  conception.  Her  husband 
could  not  remain  much  longer  away  from  home.  I  pro- 
posed to  repeat  the  operation  of  incising  the  os  and 
cervix,  to  which,  like  a  true  woman,  she  at  once  assent- 
ed, and  it  was  done  after  the  next  menstruation.  In  a 
few  weeks  (January,  1859),  she  was  pronounced  fit  for 
the  married  life.  The  os  was  open,  and  the  uterus  held 
erect  by  a  well-adjusted  instrument,  which,  as  before, 
she  was  directed  to  wear  during  coition.  Conception 
fortunately  occurred  just  after  the  next  menstruation, 
and  we  watched  her  most  carefully  during  the  whole 
period  of  utero-gestation.  She  wore  the  instrument 
nearly  up  to  the  time  of  quickening,  when  it  was  re- 
moved altogether.  •  She  now  acknowledged  to  having 
removed  it  as  soon  as  she  found  out  she  was  pregnant, 
each  time  before,  which  doubtless  had  much  to  do  with 
the  miscarriages  that  followed  the  falls.  She  went 
safely  the  full  term,  and  was  delivered  by  Dr.  Griscom, 
of  a  son,  on  the  1st  December,  1859. 

We  kept  this  patient  in  the  horizontal  position  for 
five  or  six  weeks  after  confinement,  with  the  hope  that 
a  perfect  involution  would  be  effected  before  she  re- 
sumed the  erect  posture,  and  that  the  uterus  might 
stand  a  good  chance  of  remaining  in  its  proper  position 
afterwards  without  instrumental  aid.  When  she  left 
for  the  South,  two  months  after  her  delivery,  the  uterus 
remained  in  a  normal  position ;  but  the  best  evidence 
of  a  perfect  cure  having  been  effected,  is  afforded  by  the 
fact  that  fifteen  months  after  her  confinement  in  New 
York,  she  was  safely  delivered  of  twins  at  her  home  in 
the  South. 

This  case  is  interesting  in  many  particulars  :— 
1st.  It  shows,  what  has  been   observed  by  others, 
and  what  I  have  seen  many  times   before  and  since, 


UTERINE    DISPLACEMENTS.  283 

that  a  fibroid  tumour  does  not  necessarily  impede 
conception,  gestation,  or  delivery,  all  other  things  being 
equal. 

2nd.  It  shows  that  it  is  possible,  even  in  very  diffi- 
cult cases, 'to  understand  the  obstacles  to  conception,  and 
to  remove  them  by  persistent  continued  effort,  if  our 
patient  has  sufficient  fortitude  and  endurance. 

3rd.  It  shows  that  it  is  possible  to  cure  a  retrover- 
sion, and  even  to  cause  the  disappearance  of  a  fibroid 
by  the  modified  nutrition  of  utero-gestation. 

I  am  awaxe  that  this  reiteration  of  cases  is  irksome ; 
but,  as  I  have  said  before,  I  write  mainly  for  the  young 
and  inexperienced ;  and  how  am  I  to  impress  upon 
their  minds  the  truth  of  my  views  but  by  giving  them 
the  facts  and  circumstances  that  have  gradually  led  my 
own  convictions  where  I  myself  find  them,  without 
any  prejudices  or  preconceived  opinions  on  the  sub- 
ject? 

I  could  here  detail  many,  very  many  cases  like  those 
already  related ;  but  enough  has  been  said,  and  I  leave 
this  part  of  the  subject  with  the  simple  statement  of  the 
above  facts,  which  strike  me  as  having  an  important 
bearing  on  the  subject  under  consideration. 

It  might  be  supposed  from  what  I  have  said  about 
pessaries,  that  every  case  of  retroversion  is  capable  of 
being  rectified  by  an  instrument.  If  so,  let  me  hasten 
to  correct  the  error.  I  am  sorry  to  say  that  there  are 
numbers  of  cases  in  which  a  pessary  is  absolutely  out 
of  the  question.  In  many  women  the  vagina  is  so  deli- 
cately organized  that  it  is  perfectly  intolerant  of  any 
hard  substance,  and  in  a  few,  about  the  time  of  change 
of  life,  it  will  not  bear  the  presence  of  a  soft  sponge, 
or  even  a  bit  of  cotton.  In  some  there  is  a  chronic 
metritis,    which    forbids    mechanical    means ;    and    in 


284  UTERINE    SURGERY. 

others  peri-uterine  inflammation  or  a  prolapsed  inflamed 
ovary. 

We  occasionally  find  a  retroversion  conjoined  with 
an  anteflexion.  "When  this  is  the  case,  the  infra-vaginal 
cervix  is  almost  always  too  long ;  and  we  often  find  the 
supra-vaginal  portion  indurated,  tender,  and  very  sensi- 
tive, just  above  the  insertion  of  the  posterior  wall  of 
the  vagina.  In  such  cases  it  will  be  impossible  for  the 
patient  to  wear  a  pessary,  on  account  of  its  pressure 
behind  the  cervix.  I  have  not  as  yet  amputated  a  cervix 
under  these  circumstances,  but  I  am  very  sure  that  it 
would  be  better  to  do  this,  if  we  wish  to  treat  the  sterile 
condition  successfully.  I  have  been  in  the  habit  latterly 
of  managing  these  obstinate  cases  simply  by  introducing 
a  plug  of  fine  cotton,  or,  as  it  is  called  in  Eng- 
land, cotton-wool.  I  have  alluded  to  this  before,  p. 
245. 

A  pessary  of  cotton  can  be  worn  with  great  comfort 
if  the  vagina  itself  is  in  a  normal  condition.  In  pre- 
paring it,  we  must  be  careful  not  to  pull  the  cotton  in 
pieces,  but  let  it  be  one  compact  mass  of  the  desired 
size,  carefully  tied  in  the  middle  with  a  strong  thread 
for  its  ready  removal.  We  may  use  it  simply  so,  or 
medicated  with  glycerine  or  tannin,  or  anything  else  we 
may  wish.  If  it  is  unmedicated,  it  must  not  be  worn 
longer  than  twenty-four  hours.  It  is  enough  to  wear 
it  while  awake.  If  we  use  glycerine,  we  may  leave  this 
tampon  pessary  two  or  three  days,  or  till  it  falls  out. 
The  glycerine  is  disinfectant,  and  the  cotton  remains 
without  odour.  It  is  important  for  the  convenience  and 
comfort  of  the  patient,  to  teach  her  to  apply  and  remove 
the  cotton  pessary  herself.  For  this  purpose  I  have 
invented  a  porte-tampon,  which  answers  a  most  admi- 
rable purpose. 


UTERINE    DISPLACEMENTS. 


285 


Fig.  114  represents  the  porte-tampon.  The  requisite 
quantity  of  cotton,  tied  in  the  middle  with  a  strong 
thread  some  eight  or  ten  inches  long, 
is  placed  in  the  porte-tampon ;  the  lid 
is  shut;  the  instrument  is  introduced 
like  an  ordinary  speculum,  the  patient 
on  the  back ;  it  is  to  be  pushed  Urmly 
and  forcibly  backwards  and  downwards 
under  the  cervix  to  the  posterior  cul- 
de-sac.  When  we  are  satisfied  that  it 
can  go  no  further  without  producing 
pain,  then  the  piston  is  to  be  pushed 
forwards ;  the  tampon  is  left  in  its  place, 
and  the  instrument  is  withdrawn.  The 
string  previously  attached  to  the  cotton, 
hangs  from  the  vagina,  and  with  this 
the  tampon  is  removed  when  necessary. 
One,  and  almost  the  only  objection  to 
the  cotton  nowadays,  is  its  expensive- 
ness.  Tow  is  much  cheajDer,  and  an- 
swers tolerably  well.  I  have  had  many 
patients  who  could  not  remain  long 
enough  under  treatment  to  be  radically 
cured  of  engorgements,  <fec.,  who  have 
gone  away  with  a  porte-tampon  and 
appropriate  remedies,  using  it  them- 
selves, and  getting  well  without  further 
ai<l.  I  have  had  a  few  who  suffered 
from  haemorrhages  that  demanded  the 
tampon,  and  wlio  were  able  to  control 
these  by  applying  it  themselves  by  means  of  this  instru- 
ment. Of  course  they  had  to  charge  the  porte-tampon 
four,  five,  or  six  times,  fixing  a  string  to  each  bit  of 
cotton.     I  only  recommend  this  where  the  patient  is  far 


Pig.  114. 


286  UTERINE    SURGERY. 

removed  from  prompt  medical  aid,  and  wliere  even  a 
small  loss  of  blood  is  to  be  carefully  avoided. 

I  have  had  lately  under  my  care  two  most  obstinate 
cases  of  retroversion  in  which  no  sort  of  pessary  could  be 
worn  except  cotton ;  without  the  cotton  pessary,  the  uterus 
in  each  was  turned  back  to  an  angle  of  more  than  100^ 
from  a  normal  line,  but  with  this  pushed  snugly  up  into 
the  posterior  cul-de-sac,  the  organ  was  comfortably  sus- 
tained in  position.  Each  of  these  patients  conceived 
during  the  time  of  using  this  instrument.  They  were 
taught  to  apply  the  tampon  on  rising  in  the  morning, 
and  to  remove  it  on  going  to  bed  at  night.  These  are 
the  only  cases  in  which  as  yet  I  have  seen  pregnancy 
follow  the  use  of  this  sort  of  pessary.  One  of  them 
was  a  patient  of  Sir  J oseph  OUiffe.  We  tried  a  variety 
of  pessaries,  and  were  compelled  to  give  up  all  of  them, 
and  resort  to  the  cotton  pessary,  and  the  result  was  as 
stated. 

A  year  ago,  I  incised  the  cervix  uteri  in  a  case  of 
dysmenorrhoea  where  there  was  a  retroversion,  with 
anteflexion,  and  elongation  of  the  cervix,  with  indura- 
tion and  great  tenderness  of  its  posterior  portion,  just 
above  the  insertion  of  the  vagina.  The  dysmenorrhoea 
and  the  engorgement  of  the  organ  were  relieved ;  but 
the  retroversion  continued,  with  its  attendant  symptoms 
of  pain  across  the  hips,  dragging  sensations,  <fec.  On 
account  of  the  tenderness  of  the  cervix  when  pressed 
above  the  posterior  cul-de-sac,  it  was  impossible  for 
her  to  wear  any  of  the  instruments  that  I  am  in  the 
habit  of  using.  But  she  could  wear  a  small  tampon  of 
cotton  with  the  greatest  comfort.  She  writes:  "The 
uterine  support  has,  I  am  sure,  done  great  things  for 
me.  I  now  use  it  about  every  other  day :  last  month 
every  day.     My  idea  is  that  it  has  quite  succeeded  in 


UTERINE  DISPLACEMENTS. 


287 


its   purpose,  and  tliat  I  am  as  well  as  any  one  need 
be. 

Sometimes  the  broad,  flat  porte- 
tampon  above  figured  is  difiicult  of  in- 
troduction, even  in  those  who  have  borne 
children;  and  then  I  have  been  com- 
pelled to  resort  to  one  made  after  this 
fashion  (fig.  115).  The  cotton,  which' 
must  be  properly  prepared,  is  to  be 
pushed  in  at  the  open  end  of  the  instru- 
ment, and  this  is  to  be  applied  as  before  p^.^  ^^r, 
directed. 

Of  Peocidentia. — Whenever  the  cervix  uteri  passes 
through  the  mouth  of  the  vagina,  we  call  it  a  proci- 
dentia, whether  it  be  to  a  slight  or  a  great  extent. 
Thus  a  procidentia  may  be  complete  or  incom2:>lete : 
complete,  when  the  vagina  is  inverted  and  protruded 
externally ;  incomplete,  when  the  cervix  utei'i  alone 
passes  down  without  bringing  the  vagina  with  it.  It  is 
only  occasionally  that  we  see  the  cervix  alone  projecting 
between  the  labia  for  an  inch  or  two,  and  remaining 
thus  stationary  for  a  long  time ;  usually  it  goes  from  bad 
to  worse,  till  it  eventually  passes  entirely  through  the 
vulva,  forming  a  tumour  of  great  size,  which,  at  its  most 
dependent  part,  presents  the  os  tincse  often  ulcei-ated 
and  bleedinsf.  This  tumour  is  a  veritable  hernial  mass, 
consisting  sometimes  of  the  whole  uterus,  but  often er  of 
its  elongated  cervix,  the  has  fond  of  the  bladder,  and 
occasionally  intestine,  with  the  inverted  vagina  as  its 
outer  covering. 

Fig.  116  represents  an  incomplete  procidentia,  and  is 
a  type  of  its  class.  -  See  Dr.  Bennet's  case,  on  p.  2'20. 

Fig.  124,  p.  805,  represents  a  complete  procidentia, 
and  may  be  taken  as  a  type  of  its  class. 


288 


UTERINE    SURGERY. 


Several  separate  and  independent  conditions  must 
conspire  to  produce  a  result  so  opposed  to  the  designs 
of  nature.  Thus  there  must  always  be  a  broad  pubic 
arch  with  very  divergent  rami  and  a  relaxed  perineum ; 
and  then  the  axis  of  the  uterus  must  be  turned  back  in 
a  line  with  that  of  the  vagina  and  the  pelvic  outlet;  in 
other  words,  there  must  be  a  retroversion.  With  the 
uterus  anteverted,  a  procidentia  is  utterly  impossible, 
be  the  attendant  circumstances  what  they  may.  Occa- 
sionally we  see  it  as  a  result  of  the  abnormal  pressure 


Fig.  116. 


of  an  irregular  mass  of  fibroid  tumours,  which  fill  the 
pelvis  and  crowd  the  uterus  down ;  l)ut  not  even  then 
without  the  co-operating  conditions  above  cited. 

In  very  old  cases  of  procidentia,  the  vagina,  from 
long   exj^osure   to   the   air,   becomes  dry,   and    assumes 


UTERINE    DISPLACEMENTS. 


289 


almost  a  dermoid  appearance.  It  is  the  opinion  of 
many,  that  the  cervix  uteri  is  the  first  in  the  order  of 
exit,  that  it  always  comes  down,  to  open  like  a  wedge 
the  parts  through  which  the  whole  mass  descends.  I 
cannot  say,  that  this  is  not  so  at  first,  but  I  can  with 
the  greatest  confidence  say  that  it  is  not  so  in  the  great 
majority  of  cases,  when  they  become  chronic. 


Fig.  117. 

In  an  old  procidentia,  the  vagina  attains  enormous 
proportions,  in  consequence  of  its  being  constantly 
expanded  by  the  distending  power  of  its  hernial  con- 
tents. To  observe  the  order  of  descent  in  a  case  like 
this,  reduce  the  parts  to  their  normal  relations,  and  let 
the  patient  force  them  out  again,  whether  in  the  erect 

19 


290  UTERINE    SURGERY. 

posture  or  on  the  back,  and  we  shall  see  the  anterior 
wall  of  the  vagina,  first  forced  downwards  against  the 
perineum,  in  the  form  of  a  cystocele ;  a  slight  straining 
pushes  this  beyond  the  vulva,  and  the  cervix  follows 
immediately,  bringing  down  the  posterior  wall  of  the 
vagina.  If  we  would  reduce  a  procidentia  with  ease,  we 
must  invert  this  order ;  push  back  the  posterior  cul-de- 
sac  first ;  then  the  cervix  ;  and  then  the  anterior  wall  of 
the  vaofina  and  bladder  follow  as  a  matter  of  course. 

Fig.  117  is  from  a  photograph  of  a  patient  of  Dr. 
Thierry-Meig,  in  Paris,  and  represents  a  cystocele  as 
the  first  stage  of  procidentia.  By  a  little  ejffort  she 
could  effect  its  complete  protrusion.  She  is  a  German, 
twenty-three  years  of  age,  the  mother  of  three  children, 
the  youngest  being  five  months  old.  She  is  a  street- 
sweeper,  and  has  had  procidentia  ever  since  her  last 
confinement.  Besides  this  she  has  haemorrhoids,  as  seen 
in  the  cut. 

Sometimes  we  find  the  intra-vaginal  cervix  elongated, 
but  oftener  the  supra- vaginal.  Occasionally  we  see  a 
complete  descent  of  the  whole  uterus  through  the  vulva. 
However,  I  have  met  with  but  few  cases  of  this  sort. 
One  of  these  was  shown  to  me  by  Dr.  Chepmell,  of  Paris. 
It  was  the  case  of  a  maiden  lady,  some  forty  years  old, 
who  had  been  subject  to  it  for  twelve  or  fifteen  years, 
and  often  suffered  greatly  from  retention  of  urine,  and 
the  other  ordinary  attendants  of  this  affection.  The 
doctor  tells  me  that  he  has  repeatedly  found  the  proci- 
dentia girdled  by  an  ulcerated  sulcus  at  its  neck,  and 
seemingly  bordering  upon  the  verge  of  sphacelus,  in 
consequence  of  its  obstructed  circulation.  Its  great 
peculiarity  consisted  in  the  fact  that  the  uterus  was  but 
one  inch  and  a  half  deep.  Many  eminent  medical  men 
had  seen  the  case  before,  and  were  of  opinion  that  the 


UTERINE  DISPLACEMENTS.  291 

utero-cervical  canal  was  obstructed  at  this  depth  by 
some  mechanical  barrier  that  prevented  the  further  pas- 
sage of  the  probe ;  but  we  were  able  to  settle  this  point 
very  easily,  by  palpation  alone,  while  the  uterus  was  in 
the  pelvis-;  and  when  it  came  down,  it  passed  entirely 
through  the  vulva,  and  we  could  easily  grasp  it  between 
the  two  hands,  by  passing  the  index-finger  of  one  hand 
into  the  rectum,  and  hooking  it  forwards  over  the 
fundus,  while  pressure  was  made  by  the  other  on  the 
front  of  the  tumour,  just  below  the  urethra.  Indeed  we 
could  even  tilt  the  fundus  downwards  and  backwards 
across  the  long  axis  of  the  procidentia ;  and  this  move- 
ment gave  us  great  facility  in  diagnosing  the  contents 
of  this  great  hernial  protrusion,  which  consisted  of 
intestine  as  well  as  of  uterus  and  bladder.  In  this  case 
the  vagina  was  immense,  the  perineum  greatly  relaxed, 
and  the  pubic  rami  unusually  divergent. 

But  while  we  only  occasionally  find  a  procidentia 
thus  associated  with  a  uterus,  under  or  even  of  normal 
size,  we  often  find  it  where  there  is  hypertrophy  of  some 
part  of  this  oigan.  For  instance,  there  may  be  hyj^er- 
trophy  of  the  cervix,  or  merely  elongation  of  its  intra- 
vaginal  portion,  or  of  the  supra-vaginal  portion  ;  if  the 
former,  the  body  of  the  uterus  may  be  of  normal  pro- 
portions ;  if  the  latter,  it  is  more  apt  to  be  hypertro- 
phied.  And  sometimes  the  cervix  is  elongated  in  its 
two  segments,  both  infra  and  supra-vaginal. 

In  these  cases  of  cervical  elongation,  we  often  find 
the  utero-cervical  canal  four  and  five  inches  deep ;  the 
supra-vagin.'d  portion  of  the  cervix  being  slender,  atte- 
nuated, and,  when  examined  per  rectum,  feeling  not  larger 
than  the  finger.  This  elongation  is  evidently  secondary. 
I  believe  it  to  be  a  sequence  of  the  procidentia,  for  we 
are  more  apt  to  find  supra-vaginal  elongation  where  the 


292  UTERINE    SURGERY. 

fundus  uteri  is  from  some  cause  or  other  too  large  to 
pass  out  of  the  pelvis.  If  tlie  body  of  the  uterus  passes 
out  of  the  pelvis,  there  is  no  supra- vaginal  elongation ; 
if  not,  there  is ;  and  for  the  simplest  reason.  Suppose 
the  cervix  uteri  projecting  through  the  vulva,  the  fundus, 
from  some  cause,  cannot  follow,  but  remains  fixed,  as  it 
were,  within  the  pelvis  by  hypertrophic  or  fibroid 
enlargement ;  the  cervix  once  through  the  vulva,  pres- 
sure around  it  from  above  soon  pushes  down  the  two 
culs-de-sac,  resulting  in  a  de  facto  hernia.  This  gets 
larger  and  larger,  and  the  uterus  retained  in  the  pelvic 
cavity  becomes  one  of  the  principal  points  of  support 
for  this  mass,  which  hangs  by  the  cervix,  and  the  cervix 
consequently  becomes  not  hypertrophied  but  attenuated 
and  elongated,  feeling  like  a  mere  cord,  not  more  than 
half  its  normal  size.  And  this  elongation  is  gradually 
produced  by  these  two  antagonistic  forces ;  one  acting 
on  the  body  of  the  uterus  to  retain  it  in  the  pelvic 
cavity,  the  other  on  the  lower  end  of  the  cervix,  to  push 
it  downwards. 

When  the  procidentia  is  due  to  a  mass  of  tumours 
filling  the  pelvic  cavity,  and  crowding  the  uterus  down- 
wards, as  I  have  seen  in  several  instances,  we  cannot, 
I  regret  to  say,  promise  much  relief. 

Fig.  118  represents  a  procidentia  of  more  than  twenty 
years'  standing,  in  a  woman  nearly  seventy  years  of 
age,  whose  pelvis  was  filled  with  a  number  of  small 
fibroids  of  bony  hardness.  One  large  tumour  is  not  so 
apt  to  produce  procidentia  as  several  smaller  ones, 
say  from  the  size  of  an  orange  to  that  of  the  fist, 
loosely  bound  together;  because  the  single  one  may 
grow  large  enough  to  rise  above  and  rest  upon  the 
brim  of  the  pelvis,  while  the  smaller  ones  accommo- 
date themselves  to  the  pelvic  cavity,  displacing  what- 


UTERINE    DISPLACEMENTS. 


293 


ever  may  interfere  with  their  development.  The  above 
was  the  largest  hernial  procidentia  I  have  ever  seen. 
It  reached  nearly  half-way  down  the  thighs,  and  con- 
tained a  large  quantity  of  intestine.  When  it  was 
reduced  She  felt  less  comfortable  than  when  it  pro- 
truded. On  this  account  no  effort  was  made  for  its 
relief. 

Huguier    has    written    extensively    on    procidentia 


1 

;:- 

1 

^~^; 

|: 

^ 

#- 

fe 

/■$^ 

► 

,  -"    'i 

^ 


Fig.  118, 


uteri,  and  I  believe  he  was  the  first  to  point  out  the 
distinctive  characteristics  of  its  anatomical  peculiai'ities. 
He  found  elongation  of  the  cervix  in  all  cases,  either 
above  or  below  the  insertion  of  the  vagina;  and  he 
suggested  and  performed  amputation  of  the  neck  of 
the  uterus  in  every  case,  and  with  great  success.     For 


294  UTERINE  SURGERY. 

special  information  in  regard  to  his  views,  I  must  refer 
the  readei"  to  his  memoir.* 

I  amputate  the  cervix  only  when  its  lower  segment 
is  too  large  or  tot*  long,  and  projects  so  far  into  the 
vagina  as  to  present  a  mechanical  obstacle  to  the 
retention  of  the  uterus  in  -ntu  when  replaced.  This 
will  be  sufficient  in  some  cases,  such  as  that  met  with 
by  Dr.  A.  K.  Gardner,  of  New  Yoi'k,  who  amputated 
a  cervix  weighing  §iv.  3ij.  3ij.,  which  is,  perhaps,  "the 
largest  on  record  as  having  been  removed  during  life."f 
Dr.  Gardner  says,  "The  organ  drew  up  far  into  the 
vagina  after  the  portion  was  removed,  and  in  order  to 
arrest  a  persistent  haemorrhage  it  was  necessary  to  draw 
it  down  into  view  with  hooks."  Of  course  all  such 
cases  as  this  are  readily  cured  by  amputation,  and,  as  a 
rule,  it  is  the  only  thing  to  be  done.  But  this  is  nob  a 
type  of  the  great  class  of  cases  that  we  are  called  upon 
to  treat.  If  there  should  be  elongation  of  the  infra- 
vaginal  cervix,  amputation  is  the  remedy ;  but  we  often 
find  procidentia  without  any  extraordinary  elongation 
of  the  infra- vaginal  portion  of  the  cervix.  There  is  then 
nothing  to  amputate. 

In  these  cases  Mr.  Baker  Brown,  Dr.  Savage,  and 
others,  contract  the  vulvar  outlet  by  the  perineal  opera- 
tion ;  but  generally  I  prefer  to  narrow  the  vagina  above, 
which  usually  very  effectually  retains  the  uterus  in  some- 
thing like  a  normal  position  within  the  pelvis. 


*  "Memoire  sur  les  AUongements  hypertrophiques  du  Col  de  I'Uterug 
dans  les  Affections  designees  sous  les  noms  de  Descente,  de  Precipitation 
de  cet  Organe,  et  sur  leur  traitement  par  la  resection,  ou  1  amputation  de  la 
totalile  du  Col,  suivant  la  variete  de  la  Maladie."  Par  jP.  C.  Huguier, 
Membre  de  I'Academie  Imperiale  deMedecine,  &c.  Paris:  J.  B.  Baillidre  et 
Fils.     1860. 

t  "Amputation  of  the  Cervix  Uteri."  By  A.  K.  Gardner,  M.D ,  Pro£, 
<fec.  &c. 


UTERINE    DISPLACEMENTS.  295 

The  idea  of  narrowing  the  vagina  is  by  no  means 
new.  I  suppose  we  may  justly  claim  it  for  the  great 
Marshall  Hall.  However  I  do  not  think  the  operation 
ever  succeeded  till  my  own  day, — and  this  success  is 
due  wholly  to  metallic  sutures. 

I  propose  now  to  give  a  brief  sketch  of  the  steps  by 
which  we  arrived  at  the  method  of  operating  herein 
advocated. 

In  1856,  Dr.  Warren  Stone  and  Dr.  Axson,  of  'New 
Orleans,  referred  a  patient  of  theirs  to  my  care,  who 
had  had  procidentia  for  three  years.  She  was  about 
thirty  years  of  age,  tall,  slender,  and  bony,  and  had 
enjoyed  good  health  till  the  yellow-fever  epidemic  of 
1853,  in  New  Orleans.  The  labour,  lifting,  and  fatigue 
which  she  underwent  as  a  nurse  durino^  that  terrible 
epidemic  left  her  with  a  double  inguinal  hernia  and  a 
complete  procidentia  uteri.  I  have  seldom  seen  a  more 
distressing  case.  She  wore  a  double  truss  for  the 
hernial  protrusions ;  and,  for  the  procidentia,  the  largest 
globe-pessary  that  I  ever  saw.  But  notwithstanding  the 
immense  size  of  the  globe,  which  was  nine  inches  in  cir- 
cumference, it  was  impossible  for  her  to  retain  it  in  the 
vagina  by  any  bandage ;  so  it  was  constantly  slipping 
away,  and  that  too  at  rather  inopportune  moments.  I 
arranged  a  pessary  with  a  stem  and  a  T  bandage,  which 
kept  the  parts  within  the  pelvis.  In  the  course  of  two 
months  she  had  regained  some  25  pounds  of  flesh,  and 
was  on  the  eve  of  returning  home  harnessed  up  with 
trusses  and  bandages  to  a  most  uncomfortable  degree, 
when  I  happened  to  ask  her  if  she  would  be  willing  to 
submit  to  a  surgical  operation,  if  we  could  promise  to 
get  rid  of  the  pessary  and  its  bandage.  She  promptly 
replied,  "Yes." 

Previously  to  this  we  had  been  in  the  habit  of  per- 


295  UTERINE    SURGERY. 

forming  tlie  perineal  operation  after  the  plan  of  Mr. 
Baker  Brown,  and  for  some  reason  we  had  not  been 
successful.  Dr.  Emmet  and  myself  both  thought  that 
we  could  hardly  promise  any  better  success  by  it  in  this 
case  than  we  had  formerly  met  with.  This  was  the  first 
time  that  I  had  had  a  good  opportunity  of  observing 
and  studying  the  manner  in  which  the  procidentia 
occurred.  After  replacing  it  and  allowing  it  to  descend 
again,  which  always  occurred  very  quickly  on  assuming 
the  erect  posture,  I  noticed,  as  before  described,  that  the 
descent  was  not  at  first  by  the  protrusion  of  the  cervix 
uteri,  but  invariably  by  a  prolapse  of  the  anterior  wall 
of  the  vagina,  which  always  preceded  the  cervix,  and 
drew  down  the  uterus.  I  found  that  this  cystocele  was 
but  another  hernia  (she  had  double  inguinal  hernia), 
and  I  discovered  that  she  could  not  force  it  down  again, 
when  simply  the  point  of  the  index  finger  was  held  in 
the  anterior  cul-de-sac.  Then  by  pinching  up  the  ante- 
rior wall  of  the  vagina  into  a  longitudinal  fold,  with  two 
tenacula  or  a  pair  of  forceps,  I  saw  that  the  parts  had 
no  tendency  whatever  to  come  down ;  and  that  it  was 
impossible  for  our  patient  to  force  them  down  if  we  thus 
prevented  the  anterior  wall  of  the  vagina  from  descend- 
ing. Hence  the  idea  of  wholly  removing  the  redundant 
portion  of  the  anterior  wall  of  the  vagina  occurred  to 
me ;  but  it  did  not  occur  to  me  to  operate  simply  by 
removing  strips  of  vaginal  mucous  membrane.  I  seri- 
ously'' proposed  to  this  lady  to  make  a  complete  vesico- 
vaginal fistula,  by  removing  at  once,  as  it  were,  a  large 
portion  of  the  base  of  the  bladder  with  the  anterior  wall 
of  the  vagina.  She  agreed  to  it ;  and  I  laid  the  plan  of 
operating  before  the  Consulting  Board  of  the  Hospital, 
and  it  was  adopted,  The  vagina  and  its  outlet  were 
enormous.     When  the  patient  was  placed  on  the  knees, 


UTERINE    DISPLACEMENTS. 


297 


or  on  the  left  side,  with  the  perineum  elevated  by  the 
speculum,  it  presented  about  the  relative  proportion 
shown  in  fig.  119.  The  measurements  made  repeatedly 
by  Dr.  Emmet  and  myself,  gave  the  following  propor- 


FiG.  119. 


tions.  From  the  meatus  urinarlus  to  the  perineum, 
a  to  Z»,  when  this  was  pulled  back  by  the  si^eculum, 
was  three  inches  ;  from  the  meatus  urinarius  to  the  pos- 
terior cul-de-sac,  a  to  c,  five  inches  and  a  quarter ; 
broadest  transverse  diameter,  four  inches  and  a  quarter  ; 
broadest  aiitero-posterior,  d  to  e^  three  inches  and  a  half. 
Proposing  to  excise  the  anterior  wall  of  the  vagina, 
I  hooked  it  up  with  a  tenaculum  at  d^  pulled  it  well 
towards  the  posterior  wall,  e^  and  then  grasped  the  base 
of  the  mass  thus  elevated  with  a  pair  of  curved  forceps 
made  for  the  purpose,  on  the  principle  of  Ricord's  phy- 
mosis  forceps,  which  held  the  parts  firmly  embraced, 
while  with  scissors  cutting  under  the  forceps  I  removed, 
at  once,  a  very  large  portion  of  the  anterior  wall  of  the 
vagina.  The  portion  removed  measured  two  inches  and 
a  half  transversely,  by  two  inches  and  five-eighths  longi- 
tudinally, and  was  very  thick.  The  chasm  made  by 
this  operation  was  fearful ;  the  lateral  retraction  of  the 


298 


UTERINE   SURGERY. 


divided  edges  being  so  ^eat  as  to  present  at  a  superficial 
glance   some   difficulty  in  bringing  them   together  by 
sutures.     There  was,  however,  no  trouble  whatever. 
Fig.  120  would  represent  a  side  view  of  one  blade, 


Fig.  120. 

a^  of  the  forceps,  as  it  grasped  the  portion  (?,  to  be 
removed.  The  bleeding  was  not  profuse  ;  but  I  at  once 
rapidly  filled  the  chasm  with  cotton,  to  stop  the  haemor- 
rhage by  pressure.  A  few  minutes  sufficed  for  this ; 
and  then  the  tampon  was  removed  for  the  purpose  of 
closing  the  edges  of  the  opening  by  transverse  sutures. 
My  surprise  was  equalled  only  by  my  delight,  when  I 
found  that  I  had  not  succeeded  in  doinof  what  I  intend- 
ed ;  for  instead  of  excisinsj  the  base  of  the  bladder  with 
the  anterior  wall  of  the  vagina,  I  had,  by  the  tenacu- 
lum, simply  raised  the  hy])ertrophied  vaghial  tissue  up 
between  the  blades  of  the  foi-ceps,  luckily  separating 
it  from  the  lining  membrane  of  the  bladder,  which 
remained  intact.  Thus  by  a  mere  accident,  the  opera- 
tion was  really  far  better  than  if  I  had  succeeded  in 
accomplishing  v/hat  theoretically  I  proposed  to  do. 

Fig.  121  would  represent  about  the  relative  propor- 
tion of  vaginal  tissue  here  removed.     The  lateral  edges 


UTERINE   DISPLACEMENTS. 


299 


were  brought  together  longitudinally  by  seven  or  eight 
silver  sutures  passed  transversely,  as  represented  in  the 
diagram.  She  was  soon  well,  and  is  so  to  this  day. 
The  operation  was  done    nine  years  ago.      The  good 


Fig.  121. 

result  in  this  case  led  me  to  operate  on  others  after- 
wards, by  a  simple  denudation  of  the  vaginal  epithelium 
to  the  same  extent  as  shown  above.  One  gi-eat  objec- 
tion to  this  method  was,  that  the  necessarily  tedious 
scarification  permitted  the  loss  of  too  much  blood; 
another  was  the  danger  of  an  abscess  forming  in  conse- 
quence of  the  central  part  of  the  scarified  portion  not 
being  closely  embraced  by  the  sutures.  Foi-  instance,  it 
will  be  seen  by  reference  to  the  diagram,  that  when  the 
sutures  were  closed,  bringing  the  outer  edges  into 
apposition,  the  centi-al  portion  of  denuded  tissue  not 
included  by  them  would  necessarily  be  thrown  into  a 


300  UTERINE    SURGERY. 

fold  that  would  project  the  mucous  membrane  of  the 
bladder  into  a  sort  of  longitudinal  ridge  along  the  has 
fond.  I  was  at  first  afraid  that  this  loose  tissue  might 
not  be  held  firmly  enough  together  to  unite  by  the  first 
intention;  and  in  one  instance  an  abscess  formed  that 
gave  rise  to  some  constitutional  disturbance.  But  its 
nature  and  seat  being  detected,  the  removal  of  a  suture 
at  the  upper  angle  of  the  wound,  near  the  cervix  uteri, 
promptly  evacuated  the  matter,  and  relieved  all  suffering. 
However,  this  method  of  operating  was  continued  till 
1858,  when  an  elderly  woman,  with  an  enormous  pro- 
cidentia of  fifteen  or  twenty  years'  standing,  was  sent 
to  the  Woman's  Hospital,  by  Dr.  Duane,  of  Schenec- 
tady. It  was  a  very  bad  case  indeed.  I  operated  by 
the  plan  of  simple  denudation  of  the  mucous  mem- 
brane over  a  surface  extending  from  the  neck  of  the 
bladder  to  the  neck  of  the  uterus,  and  being  two 
inches  and  a  half  in  its  largest  transverse  diameter; 
the  lateral  edges  were  united  by  silver  sutures,  and 
the  parts  healed  kindly.  But  I  did  not  remove 
tissue  enough,  and  there  was  a  considerable  cystocele 
left.  1  felt  pretty  sure  that  the  original  trouble 
would  be  reproduced,  unless  she  should  wear  con- 
stantly some  sort  of  a  pessary.  Accordingly  I  fitted 
one,  and  sent  her  home  in  a  very  comfortable  condition. 
I  was  quite  satisfied,  and  so  was  my  patient;  but  when 
she  got  home,  the  physician  who  had  had  charge  of  her 
case  before  she  consulted  Dr.  Duane,  ridiculed  the  idea 
of  her  being  cured  by  a  surgical  operation,  if  it  were 
necessary  for  her  still  to  wear  an  instrument  afterwards. 
Although  she  was  perfectly  comfortable,  she  returned  in 
two  or  three  months,  and  asked  to  be  readmitted  to  the 
Hospital.  She  said  she  wished  simply  to  prove  to  her 
physician    at    home    that    she  could    be   cured    by  an 


UTERINE    DISPLACEMENTS. 


301 


operation,  so  as  not  to  be  compelled  to  wear  a  pessary. 
Her  pluck  challenged  my  inventive  faculties,  and  then 
it  was  that  I  devised  another  method  of  operating. 
For  instance,  instead  of  the  broad  scarification  of  the 
anterior  wall  of  the  vagina,  as  before,  I  simply  removed 
the  mucous  membrane  in  the  form  of  a  V  (fis-  122, 
a  ^),  the  apex  being  near  the  neck  of  the  bladder,  and 


Fig.  122. 


the  two  arms  extending  up  on  the  sides  of  the  cervix 
uteri.  These  two  denuded  surfaces  were  brought 
together  by  silver  sutures  passed  transversely,  thus 
making  a  longitudinal  fold  narrowing  the  vagina  and 
crowding  the  cervix  backwards.  This  simple  operation 
was  thus  repeatedly  perfoi-med,  and  always  successfully, 
by  Dr.  Emmet  and  myself,  at  the  Woman's  Hospital, 
from  1858  to  1862,  when  I  left  New  York. 

In  Paris  I  had  occasion  to  perform  it  for  Sir  Joseph 


302 


UTERINE    SUEGERT. 


Olliffe  on  an  old  lady  sixty-five  years  of  age,  who  had 
had  procidentia  for  twenty  years.  The  parts  united ; 
the  uterus  was  held  in  its  place,  and  she  returned  home 
in  a  fortnight.     Her  general  health  was  very  feeble,  in 


Fig.  123. 

consequence  of  a  long  residence  in  India;  and  in  two 
months  the  whole  cicatrix  gradually  gave  way,  and  the 
procidentia  was  reproduced.  This  was  the  first  and 
only  case  of  failure  that  I  had  ever  seen  after  this 
method.  The  operation  was  subsequently  repeated  ; 
but  this  time,  instead  of  a  V-shaped  scarification,  it  was 
made  in  the  form  of  a  trowel,  as  represented  in  fig.  123, 
the  point  presenting  below,  the  shoulders  above  in  the 
anterior  cul-de-sac.  The  denuded  surfaces  a  c  and  h  d 
were  brought  together  by  transverse  silver  sutures.  A 
small  portion  of  tissue  was  left  undenuded  at  6,  between 
c  and  d^  for  the  purpose  of  permitting  the  escape  of ' 


UTERINE  DISPLACEMENTS.  3(3 

any  secretions   naturally   forming   in   the  shut    pouch 

Although  she  is  an  opium-eater,  and  frequently  has 
attacks  of  diarrhoea,  in  consequence  of  its  inordinate  use, 
as  we  often  see,  the  operation  was  successful,  and  the 
uterus  still  remains  in  its  normal  position.  This  last 
operation  was  performed  with  the  assistance  of  Sir 
Joseph  Olliffe  and  Dr.  Johnston,  of  Paris,  and  Pi-ofessor 
Pope,  of  St.  Louis. 

Dr.  Emmet*  has  recently  called  attention  to  a  source 
of  trouble  when  the  operation  is  performed  by  a  simple 
V-shaped  denudation,  as  shown  in  fig.  122.  He  says, 
"  Previous  to  the  time  of  Dr.  Sims's  removal  to  Europe 
in  1862,  we  both  had  operated  frequently  without  the 
necessity  for  any  modification  occurring. 

"In  September,  1862,  after  three  months  of  great 
suffering,  one  of  the  first  patients  operated  on  by  Dr. 
Sims  in  this  manner,  presented  herself  at  the  Hospital, 
for  relief.  She  stated  that,  during  four  years,  she  had 
been  entirely  relieved  by  the  operation,  when,  suddenly 
(while  in  the  act  of  lifting)  she  was  seized  with  a 
persistent  tenesmus,  greatly  aggravated  in  the  upright 
position. 

"  On  examination,  the  line  of  union  was  found  per- 
fect, with  no  prolapse  of  the  vaginal  wall.  But  the 
neck  of  the  uterus  had  slipped  behind  the  septum  into 
the  pouch,  thus  throwing  the  fundus  into  the  hollow  of 
the  sacrum,  and  fixing  the  organ  in  this  position.  With 
great  difficulty,  the  neck  was  disengaged.  On  returning 
the  uterus  to  its  normal  position,  immediate  relief  was 


*  New  York  Medical  Journal,  vol.  i.,  No.  I.  April,  1865.  "  A  Radical 
Operation  for  Procidentia  Uteri."  By  Thomas  Addis  Emmet,  M.D.,  Surgeou 
to  the  Woman's  Hospital. 


304  UTERINE    SURGERY. 

obtalnecl,  and  she  waj<  discliarged  without  further  trer.t- 
raeut."  This  case  was  subsequently  operated  upon  by 
Dr.  Emmet. 

After  this,  Dr.  Emmet  hunted  up  two  patients  upon 
whom  he  had  operated  eighteen  months  before,  and  he 
found  the  uterus  retro  verted  in  each  one,  with  the  cervix 
resting  behind  the  pouch  made  by  bringing  together  the 
two  denuded  surfaces  a  h^  fig.  122.  To  remedy  this 
defect,  in  his  subsequent  operations  he  simply  denuded 
the  vaginal  mucous  membrane  in  a  line  across  the  cul- 
de-sac  between  these  two  points,  as  shown  by  the  dotted 
line  <?, -fig.  122,  making  a  regular  triangle  with  its  apex 
at  the  neck  of  the  bladder,  and  base  at  the  cei'vix  uteri. 
In  January,  1864,  Dr.  Emmet  operated  on  a  very  unruly 
patient,  who,  during  the  night  after  the  operation,  "got 
up  and  walked  about  the  ward  for  several  hours,  and 
continued,  in  spite  of  all  remonstrance,  to  follow  her 
own  inclination.  On  the  twelfth  day,  it  was  discovered 
that  four  sutures  (near  the  neck  of  the  bladder)  had 
torn  out,  and  through  the  gap  a  portion  of  the  relaxed 
base  of  the  bladder  protruded.  The  sutures  were  all 
removed  at  the  time,  and  every  hope  of  success  aban- 
doned. Before  her  discharge,  it  was  found  on  examina- 
tion that  the  entire  line  of  union  had  gradually  parted, 
with  the  exception  of  the  cross  scarification,  in  front  of 
the  cervix  uteri.  The  fold  thus  formed  (as  in  a  sling) 
had  retained  the  organ  perfectly  in  place,  although 
below,  a  cystocele  existed.  Fature  experience  must 
demonstrate  how  far  the  formation  of  this  fold  can  alone 
be  relied  on  under  other  circumstances ;  yet  it  is  evident 
that  in  many  cases  this  will  prove  all  that  is  necessary  to 
retain  the  uterus  in  situr 

It  is  always  interesting  to  watch  the  slow  degrees  by 
which  true  principles  of  treatment  are  established.    The 


UTERINE    DISPLACEMENTS. 


305 


idea  of  narrowing  tlie  vagina  for  the  cure  of  procidentia 
was  first  suggested  by  Marshall  Hall,  but  I  do  not  know 
that  the  operation  ever  succeeded.  Then  I  carried  out 
the  principle  by  cutting  away  the  whole  of  the  redun- 


^;,fli//'£> 


Fig.  124. 


dant  portion  of  the  anterior  wall  of  the  vagina  (fig.  120). 
This  I  afterwards  modified  by  simply  denuding  a  large 
oval  surface  on  the  anterior  wall,  and  unitins:  its  lateral 
edges  by  silver  sutures.  This  was  fui'ther  modified  by 
making  a  'y'-shaped  scarification  (fig.  122),  and  produc- 
ing a  veritable  fold  in  the  wall  of  the  vagina.  Then  I 
made  the  y  trowel-shaped,  by  turning  its  upper  ends 
inwards  across  the  axis  of  the  vagina,  in  Sir  Joseph 
Olliffe's  case,  fig.  123.  Then  Dr.  Emmet  made 
this  a  complete  triangle,  and  eventually  an  accident 
showed  him  that  merely  a  narrowing  of  the  vagina  just 


306 


UTERINE   SURGERY. 


at  the  anterior  cul-de-sac,  at  least  in  one  case,  answers 
every  purpose  of  holding  the  uterus  in  its  place. 

The  mechanical  execution  of  this  operation  is  a  matter 
of  some  nicety,  but  it  is  by  no  means  difficult.  Suppose 
we  have  such  a  case  as  the  one  represented  in  fig.  124, 
which  may  be  taken  as  a  type  of  its  class ;  we  wish  to 
narrow  the  vagina  to  keep  the  parts  in  their  normal 
relations.  We  would  suppose,  a  priori^  that  the  opera- 
tion could  be  done  more  easily  and  exactly  with  the 
uterus  thus  protruded  ;  but  it  is  a  great  mistake.  The 
uterus  must  first  be  restored  to  its  proper  position,  and 
if  the  OS  tincse  is  ulcerated,  as  here  represented,  or  if 
the  vagina  is  dry,  scaly,  and  skin-like,  it  will  be  well  to 
apply  glycerine  on  a  tampon  of  cotton,  for  a  few  days, 
till  the  ulcerations  are  healed  and  the  vagina  assumes 
more  of  a  normal  ap23earance  ;  after  which 
the  operation  may  be  performed.  For 
this  purpose,  the  patient  is  to  be  placed 
on  the  left  side,  as  so  often  before  de- 
scribed, with  my  speculum  introduced  to 
pull  back  the  perineum  and  posterior  wall 
of  the  vagina.  We  can  then  get  an 
accurate  idea  of  the  dimensions  of  the 
over-distended  vagina,  and  with  a  small 
tenaculum  hooked  into  the  mucous  mem- 
brane on  each  side  of  the  middle  line  of 
the  anterior  wall,  we  can  approximate 
these  surfaces,  and  thus  determine  whether 
we  should  make  the  denudation  of  tissue 
to  a  greater  or  less  extent  on  either  side. 
There  was  at  first  some  little  trouble  in 
making  the  two  arms  of  the  V  equilate- 
ral ;  sometimes  one  Avould  diverge  a  little 
more  from  the  median  line  on  one  side  than  the  other ; 


Fig.  125. 


UTERINE    DISPLACEMENTS. 


307 


but  this  was  overcome  by  using  an  ordinary  malleable 
uterine  sound  curved  as  represented  in  fig.  ]25.  Its 
convexity  rests  centrally  along  the  middle  line  of  the 
anterior  wall,  the  distal  end  pushes  back  the  cervix  uteri, 
while  the  counter-curvature  lies  in  contact  with  the  ure- 
thra. By  thus  pushing  the  neck  of  the  uterus  back  in  a 
straight  line,  while  the  antei'ior  wall  is  depressed  cen- 
trally, the  curvature  of  the  sound  is  hidden  from  view  by 
the  lateral  folds  of  the  vagina,  which  fall  over  it  and  meet 
in  the  middle  line,  showing  us  exactly  where  the  tissue 
is  to  be  removed  for  the  purpose  of  uniting  the  parts 
that  thus  so  naturally  and  easily  come  together.  With 
the  parts  thus  held,  it  is  very  easy  to  denude  two  sur- 
faces a  third  of  an  inch  wide  or  more,  extending,  seem- 
ingly, almost  in  parallel  lines  from  the  neck  of  the  blad- 
der upon  each  side  of  the  cervix  uteri.  To  make  the 
transverse  line  of  denudation  join  the  upper  ends  of  these 
two  arms  of  the  V,  we  remove  the  curved  sound  and 
pull  the  cervix    downwards   with  a  small    tenaculum. 


Fig.  126. 


We  must  be  careful  not  to  make  the  arms  of  the  V  ^oo 
divergent,  and  at  the  same  time  we  must  avoid  running 


308  UTERINE    SURaERT. 

them  too  closely  together.  They  should,  when  united 
by  sutures,  relieve  the  cystocele  without  putting  thp 
parts  too  much  on  the  stretch.  The  sutures  are,  of 
course,  to  be  passed  trans v^ersely,  beginning  below,  as 
represented  in  fig.  121.  The  sound  is  to  be  retained, 
pushing  the  uterus  backwards  till  we  come  to  pass  those 
near  the  cervix  uteri.  These  should  be  made  to  em- 
brace all  the  denuded  tissue,  c  J,  excluding  the  unde- 
nuded  portion  e  (fig.  123).  I  think  it  very  important 
to  leave  a  drain  here,  as  before  said,  for  the  discharge 
of  the  normal  secretions  of  the  pouch/. 

Fig.  126  represents  the  speculum  in  position,  and  the 
curved  sound  pushing  back  the  cervix  and  depressing 
the  anterior  wall  of  the  vagina. 

Dr.  Emmet  bends  the  end  of  the  sound  into  the  form 
of  a  ring,  to  fit  around  the  cervix  uteri.  Sir  Joseph 
OlHffe  suggested  the  same  thing  to  me  when  I  operated 
on  his  case  in  Paris,  but  instead  of  this  I  have  had  simply 
a  little  tenaculum  fork  at  the  end  of  the  instrument 
(fig.  125),  to  be  hooked  into  the  mucous  membrane,  just 
at  the  junction  of  the  anterior  cul-de-sac  and  the  vagina. 
This  answers  the  purpose  of  fixing  the  cervix  during  the 
whole  time  of  the  operation,  for  it  is  to  be  retained,  as 
represented  in  the  figure,  till  we  come  to  close  up  the 
sutures.  Indeed,  the  sutures  are  all  to  be  drawn  closely 
before  we  remove  it. 

Fig.  127  represents  the  instrument  superficially 
transfixing  the  mucous  membrane,  as  above  described, 
pushing  the  cervix  backwards  and  depressing  the  ante- 
rior wall  of  the  vagina,  which  rolls  over  it  in  voluminous 
folds,  forming  a  deep  central  sulcus,  along  the  borders 
of  which  the  denudation  is  to  be  made,  and  which  should 
be  more  or  less  divergent,  according  to  the  peculiarities 
and  necessities  of  the  individual  case. 


UTERINE    DISPLACEMENTS. 


309 


"When  the  operation  is  finished,  the  patient  is  to  be 
pwt  to  bed,  the  bowels  are  to  be  constipated  for  a  week, 
U'ith  a  dose  or  two  of  some  form  of  opium  in  the  twenty- 
four  iiours  ;  the  bladder  is  to  be  emptied  by  catheter 


Fig.  12T. 

when  needed,  for  two  or  three  days,  and  the  recumbent 
posture  is  to  be  enjoined  for  two  or  three  weeks.  The 
lower  sutures  may  be  removed  in  eight  or  ten  days  ;  the 
upper  should  remain  a  fortnight,  unless  there  is  some 
special  reason  for  their  eai-lier  removal.  The  patient  is 
usually  discharged  at  the  end  of  a  month  from  the  time 


310  UTERINE    SURGERY. 

of  tlie  operation,  sometimes  sooner.  I  consider  tliis 
operation  one  of  the  safest  in  sm'gery.  I  never  saw  any 
serious  accident  from  it,  and  never  saw  it  fail  but  once, 
and  that  was  in  the  case  of  Sir  Joseph  Olliffe's  patient 
(page  302),  who  was  subsequently  cured.  I  have 
operated  repeatedly  on  patients  over  sixty,  and  on  two 
that  were  seventy  years  of  age. 

Sometimes,  as  in  cases  complicated  with  rectocele,  it 
is  necessary  to  narrow  the  posterior  wall  of  the  vagina, 
as  well  as  the  anterior.  If  so,  I  prefer  to  make  two 
operations,  allowing  a  period  of  six  or  eight  weeks  to 
intervene  between  them. 

It  is  not  my  intention  to  draw  a  parallel  between 
this  and  the  perineal  operation  for  procidentia.  I  only 
wish  to  add  another  resource  to  our  means  of  permanent 
cure  in  this  distressing  affection.  I  may  state,  however, 
that  I  was  first  driven  to  the  expedient  of  working  out 
this  process  in  consequence  of  repeated  failures  of  the 
perineal  operation  in  my  hands  :  not  that  the  operation, 
as  such,  ever  failed,  but  that  the  new  perineum  made  by 
it  often  gave  way,  in  consequence  of  the  persistent  pres- 
sure of  the  parts  above.  So  far  as  mere  surgical  resources 
are  concerned,  we  have  now  three  processes  from  which 
to  choose  ;  always,  of  course,  adapting  this  choice  to  the 
peculiar  exigencies  of  the  case. 

1st.  Amputation  of  the  cervix  according  to  the  plan 
of  Huguier,  when  its  infra-vaginal  portion  is  too  long. 
I  have  often  seen  procidentia  cured  by  this  alone. 
The  case  of  Dr.  Bennett,  related  on  page  220,  is  an 
example. 

2nd.  The  perineal  operation,  as  performed  by  Mr. 
Baker  Brown,  Dr.  Savage,  and  others. 

3rd.  The  operation  of  narrowing  the  vagina  by  the 
trowel  or  triangular-shaped  denudation  on  its  anterior 


UTERINE  DISPLACEMENTS.  3X1 

wall,  as   herelu   illustrated,  and   as   performed  by  Dr, 
Emmet  and  myself. 

But  we  occasionally  meet  with  those  who  are  so  ill- 
advised  as  to  object  to  any  surgical  operation  whatever. 
What  then  are  we  to  do  ?  Meigs's  ring  and  Hodge's 
lever  utterly  fail  to  do  any  good  whatever;  globes,  disks, 
and  inflated  air-bags  all  fall  out ;  and  Zwang's  pessary  is 
the  only  mechanical  apparatus  that  promises  any  benefit ; 
and  in  old  women  this  cannot  be  tolerated  on  account 
of  the  excessively  delicate  condition,  after  change  of 
life,  of  the  vaginal  mucous  membrane  ;  for  as  life 
advances,  the  vagina  becomes  more  and  more  intolerant 
of  any  foreign  substance.  Under  these  circumstances, 
the  best  pessary  is  simply  a  small  tampon  of  cotton,  wet 
with  glycerine,  which  may  be  introduced  in  the  morn- 
ing, to  be  worn  all  day.  With  the  porte-tarapon,  figured 
on  page  285,  it  is  easy  enough  for  the  patient  to  do  this 
every  day  for  herself. 

In  April,  1865,  Dr.  Johnston,  of  Paris,  asked  me  to 
see  a  case  of  procidentia,  in  a  French  laundress,  about 
forty  years  of  age,  where  there  was  an  enormous  hyper- 
trophy of  the  cervix  uteri  (two  inches  in  diameter),  due 
to  the  development  of  numerous  little  cysts  in  its  sub- 
stance, varying  from  the  size  of  a  grain  of  wheat  to  that 
of  a  garden  pea.  Some  fifteen  or  twenty  of  these  were 
opened,  discharging  a  ropy  honey-like  fluid  ;  the  uterus 
was  then  replaced,  and  a  tampon  of  cotton  wet  with  a 
solution  of  tannin  in  glycerine  was  applied.  This  dress- 
ing was  repeated  every  other  day  for  a  month  or  two, 
when  she  became  so  comfortable  that  she  did  not 
desire  the  operation  for  a  radical  cure.  When  she 
stops  the  use  of  the  tampon,  the  uterus  descends  on 
lifting  a  heavy  weight  or  taking  a  long  walk,  but 
she    can    now  protect    herself  perfectly    against    this 


312  UTERINE    SURGERY. 

accident   by  applying    the  cotton    pessary    with    the 
porte-tampon. 

In  1853,  Professor  Fordyce  Barker,  of  the  Belle vue 
Hospital  Medical  College,  wi'ote  a  paper  on  the  treat- 
ment of  procidentia  by  the  use  of  tampons  wet  with  a 
solution  of  tannin.  Considerable  success  attended  this 
method  in  his  hands,  but  it  seemed  to  fall  into  disuse. 
Perhaps  the  porte-tampon,  as  in  the  case  above,  may 
assist  to  re-instate  the  practice.  When  patients  will  not 
submit  to  a  radical  operation,  I  have  no  doubt  that  this 
plan  may  answer  a  good  purpose,  even  if  it  does  not 
cure  the  case  permanently. 

I  had  the  honour  of  presenting  a  paper  on  Prociden- 
tia at  the  November  meeting  (1865)  of  the  Obstetrical 
Society,  which  formed  the  basis  of  an  extended  discus- 
sion. At  this  meeting,  Mr.  SjDencer  Wells  called  my 
attention  to  the  fact,  that  Marshall  Hall's  idea  of  nar- 
rowing the  vagina  was  put  into  execution  by  the  late 
Mr.  Heming,  and  that  at  least  one  case  had  been  success- 
fully operated  upon.  The  report  of  this  case  may  be 
found  in  Heming's  translation  of  Boivin  and  Duges: 
(1834),  page  53,  and  is  dated  November,  1831.  It 
affords  me  pleasure  to  make  this  correction. 


SECTION    VI. 


THE  VAGINA  MUST  BE  CAPABLE  OF  RECEIVING 
AND  OF  RETAINING  THE  SPERMATIC  FLUID. 


SECTION   VI. 

THE   VAGINA   MUST    BE    CAPABLE    OF    EEOEIVING   AND    OF 
RETAINING   THE   SPERMATIC   ELUID. 

We  here  propose  to  pass  in  review  the  usual  obstacles 
to  the  introduction  of  the  semen,  and  then  the  condi- 
tions that  prevent  its  retention  or  sojourn  in  the  vagina. 
For  it  is  not  enough  that  the  semen  be  deposited  in  the 
vagina ;  it  must  not  be  immediately  ejected. 

What,  then,  are  the  ordinary  obstacles  to  its  intro- 
duction ?  They  are  mostly  anatomical  or  mechanical, 
and  may  be  arranged  under  the  following  heads : 

1st.  The  hymen  may  be  imperforate  or  nearly  so. 

2nd.  There  may  be  vaginismus ;  i.  e.  hymeneal 
hyperaesthesia  with  a  spasmodic  contraction  of  the 
sphincter  vaginae. 

3rd.  There  may  be  atresia  of  the  vagin? 

4th.  The  vagina  may  be  wanting. 

1.  Our  medical  literature  contains  the  history  of 
many  cases  in  which  the  hymen  was  so  tough  as  to 
resist  all  reasonable  efforts  at  penetration.  And  very 
many  in  which  it  has  been  found  completely  occluded, 
with  retention  of  the  menstrual  flow.  It  is  a  little  sin- 
gular that  I  have  never  met  with  an  example  of  either 
of  these  conditions. 

All  the  cases  of  impenetrable  hymen  that  I  have 
seen  were  examples  of  vaginismus,  where  the  obstruc- 
tion was  not  in  the  mere  resisting  power  of  this  mem- 
brane, but  in  a  spasm  of  the  sphincter  muscle,  the  result 
of  the  irritable  condition  of  the  hymen. 


316  UTERINE    SURGERY. 

Where  the  hymen  is  hermetically  sealed  up  with  a 
retention  of  the  menses,  it  is  easy  enough  to  open  it  and 
evacuate  the  imprisoned  secretion  by  a  "crucial  incision," 
as  it  is  termed. 

It  is  against  this  "  crucial  incision "  that  I  would 
seriously  warn  the  inexperienced  ;  as,  simple  as  the  ope- 
ration is,  it  is  fraught  with  great  danger, — not  per  se^  but 
in  the  consequence  of  a  rapid  evacuation  of  the  retained 
fluid.  Whenever  it  is  necessary  to  perform  an  operation 
for  retained  menses,  whether  it  be  on  the  hymen,  the  os 
uteri,  or  at  any  point  along  the  vagina  between  the  two, 
it  should  always  be  done  by  a  simple  puncture  with  an 
exploring  needle,  leaving  the  gradual  evacuation  of  the 
flood  to  nature  and  to  time.  The  object  of  this  is  to 
allow  the  uterus  time  to  contract  as  its  contents  slowly 
ooze  away  This  is  a  matter  of  importance  only  where 
there  is  a  considerable  amount  of  fluid.  If  there  is  not 
more  than  an  ounce  or  two,  I  do  not  think  it  makes  any 
difference  whether  we  evacuate  it  suddenly  or  slowly. 

The  probable  amount  of  fluid  may  be  estimated 
simply  by  palpation,  which  determines  with  sufficient 
accuracy  the  size  of  the  uterus  with  its  contents. 

If  the  uterus  be  but  slightly  enlarged  by  the  retained 
fluid,  we  may  open  it  fearlessly ;  but  if  it  approach  the 
size  of  the  foetal  head,  we  should  do  it  with  the  greatest 
caution. 

Death  has  often  speedily  followed  an  incision  of  the 
hymen,  where  there  was  retention  of  the  menses.  Of 
course,  the  mere  wounding  of  the  hymen  has  nothing 
whatever  to  do  with  the  fatal  result,  which  seems  to  be 
due  to  pyaemia.  Some  think  that  this  is  caused  by  the 
admission  of  air  into  the  cavity  of  the  uterus,  which, 
having  been  over-distended,  fails  to  contract  as  rapidly 
as  the  fluid  is  evacuated.    At  the  Woman's  Hospital  we 


VAGINISMUS.  317 

have  had  repeatedly  to  evacuate  large  quantities  of 
retained  menses,  and  we  have  never  seen  any  accident 
follow.  All  our  cases  were  the  result  of  atresia  of  some 
part  of  the  vagina,  or  of  the  os  tincse.  One  only  was 
seemingly  idiopathic,  the  others  the  result  of  sloughing 
fi'om  difficult  labour. 

We  have  always  punctured  the  occluded  portion  with 
an  exploring  needle,  or  made  a  very  small  opening  with 
the  tenotomy  knife  usually  found  in  our  pocket  cases ; 
and,  knowing  the  dangers  of  the  operation,  I  must  again 
insist  on  this  point.  If  I  had  now  to  operate  on  the 
hymen  of  a  delicate  young  woman,  whose  uterus  and 
vagina  held  six  or  eight  ounces  of  fluid,  I  would  give  her 
ergot  till  its  specific  action  was  produced  on  the  uterus, 
and  then  make  a  small  puncture  in  the  hymen;  and 
this  for  the  purpose  of  insuring  uterine  contraction 
while  the  fluid  was  beino;  evacuated.  I  cannot  do  better 
than  to  quote  here  Dr.  Graily  Hewitt,  the  latest  and  one 
of  the  best  authorities  on  the  diseases  of  women.* — "  The 
plan  ordinarily  adopted  has  been,  by  means  of  a  lancet, 
or  bistoury,  or  trochar,  to  make  an  opening  in  the  hymen 
sufficient  to  allow  of  the  escape  of  the  chief  part  of  the 
retained  blood  at  once,  and  at  the  time  of  the  operation. 
I  would  suggest  that  an  opening  just  large  enough  to 
allow  of  the  escape  of  a  very  minute  quantity  of  fluid 
be  made  at  first,  and  that  this  opening  should  be  made 
obliquely  in  the  obstructing  membrane,  giving  it  a 
valvular  character.  The  fluid  should  be  evacuated  gut- 
tatim.  If  the  opening  become  closed,  a  second  and 
similar  opening  to  be  made  the  following  day,  or  two  or 
three  days  later,  and  a  firm  but  gentle  support  given  to 

*  "  Tlie  Diagnosis  and  Treatment  of  the  Diseases  of  Women."     By 
Glraily  Hewitt,  M.D.,  &c.,  &c.     London.     18G3. 


318  UTERINE  SURGEET. 

the  abdomen  by  the  aid  of  a  bandage  during  the  whole 
period  of  the  evacuation  of  the  fluid  ;  the  patient  to  be 
kept  in  a  state  of  absolute  rest.  The  aperture  in  the 
hymen  should  not  be  increased  in  size  until  the  uterus 
has  returned  to  its  proper  dimensions,  the  object-being, 
at  first,  simply  to  allow  the  fluid  to  escape  in  the  most 
gradual  manner  possible." 

Dr.  Arthur  Farre  has  given  me  the  particulars  of  a 
case  of  retained  menses,  which  was  seen  some  forty 
years  ago  by  his  father,  an  eminent  physician  of  his 
time.  A  young  lady  in  the  country  had  retention  of 
the  menses;  pregnancy  was  suspected  by  the  family 
physician  ;  Dr.  Farre  was  sent  for  to  decide  the  nature 
of  the  case;  but  before  his  arrival  the  hymen  was 
ruptured  spontaneously ;  a  large  quantity  of  retained 
menses  was  suddenly  evacuated ;  irritative  fever  set  in, 
and  the  patient  -died  in  a  few  days.  Although  I  have 
frequently  heard  of  a  fatal  result  in  similar  caseSj  as  a 
consequence  of  surgical  interference,  this  is  the  only 
one  in  which  I  have  known  it  to  happen  in  this  way. 

2.  VAGimsaros. — By  the  term  vaginismus  I  mean 
an  excessive  hypersesthesia  of  the  hymen  and  vulvar 
outlet,  associated  with  such  involuntary  spasmodic 
contraction  of  the  sphincter  vaginae  as  to  prevent 
coition.  This  irritable  spasmodic  action  is  produced 
by  the  gentlest  touch:  often  the  touch  of  a  camel's- 
hair  pencil  or  fine  feather  will  produce  such  agony  as 
to  cause  the  patient  to  shriek  out,  complaining  at  the 
same  time  that  the  pain  is  that  of  thrusting  a  sharp 
knife  into  the  sensitive  part.  This  is  worse  in  some 
than  in  others.  In  a  very  large  majority,  the  pain  and 
spasm  conjoined  are  so  great  as  to  preclude  the  possi- 
bility of  sexual  intercourse.     In  some  instances  it  will 


VAGmiSMus.  319 

be  borne  occasionallj^,  notwithstanding  the  intolerable 
suffering ;  while  in  others  it  will  be  wholly  abandoned, 
even  after  the  act  has  been  repeatedly  and,  as  it  were, 
perfectly  performed. 

We  can,  hardly  make  a  mistake  in  the  diagnosis  of 
this  affection.  It  could  be  confounded  only  with  impel** 
forate  hymen  oi'  atresia  of  the  vagina,  the  true  nature 
of  which  is  easily  ascertained  by  examination.  In  these 
there  is  not  necessarily  inordinate  pain  on  being  touch- 
ed. There  is  only  a  mechanical  impediment  to  the 
passage  of  a  probe  or  the  finger  into  the  vagina,  while 
in  the  other  the  gentlest  touch,  as  said  before,  produces 
excessive  suffering,  and  this  is  the  chief  diagnostic. 

To  examine  a  case  of  suspected  vaginismus,  place  the 
patient  on  the  back,  with  the  legs  flexed;  separate 
gently  the  labia.  The  patient  will  exhibit  signs  of 
alarm  and  agitation, — ^not  that  w^e  hurt  her,  but  she 
feels  an  indescribable,  insuperable  dread  of  being  hurt. 
She  is  like  a  timid,  nervous  person  who  has  once  had  a 
pointed  instrument  thrust  into  the  exposed  pulp  of  an 
inflamed  nerve  in  a  decayed  tooth.  The  very  idea  of 
its  repetition  throws  her  into  a  nervous  rigour.  The 
degree  of  general  disturbance  will  depend  upon  the 
peculiar  temperament  of  the  individual.  But  be  this  as 
it  may,  when  we  come  to  explore  the  seat  of  trouble, 
the  strongest  will  and  stoutest  frame  will  exhibit  unmis- 
takable signs  of  excruciating  suffering  ;  for  the  gentlest 
touch  with  the  finger,  a  probe,  even  with  a  feather,  pro- 
duces great  agony.  The  sensitiveness  is  at  all  parts  of 
the  vaginal  outlet.  It  is  very  great  at  and  near  the 
meatus  urinarius  on  each  side  where  the  hymen  takes  its 
origin ;  and  greater  still  near  the  orifice  of  the  vulvo- 
vaginal gland ;  but  often  the  most  sensitive  point  is  at 
the  fourchette,  where  the  hymen  projects  upwards.    The 


320  UTERINE  SURGERY. 

whole  vmlval  or  outer  face  of  tlie  hymen  is  sensitive,  but 
it  is  more  so  along  its  reduplication  or  base.  The  touch 
of  a  probe  or  a  camel's-hair  pencil  is  sufficient. 

But  while  the  outer  face  of  the  hymen  and  the  adja- 
cent parts  are  so  sensitive,  if  we  turn  the  patient  on  the 
left  side  and  separate  the  nates  and  vulva  so  as  to  pass 
a  sound  through  ttie  hymen  without  touching  its  outer 
surface,  and  then  make  pressure  with  it  laterally  or 
backwards  on  the  inner  or  vaginal  aspect  of  this  mem- 
brane, we  will  not  find  there  any  abnormal  degree  of 
sensitiveness. 

Touching  the  outer  surface  of  the  hymen  in  any  por- 
tion of  its  reduplication,  produces  not  only  pain,  but  an 
involuntary  spasm  of  the  sphincter  muscle  both  of  the 
vagina  and  anus.  In  some  instances,  the  sphincter  ani 
feels  as  hard  as  a  ball  of  ivory ;  and  one  of  my  patients 
supposed  it  to  be  a  tumour  that  would  require  exsec- 
tiou.  The  supersensitiveness  is  diagnostic ;  the  spasm 
pathognomonic. 

The  most  perfect  examples  of  vaginismus  that  I  have 
seen  were  uncomplicated  with  inflammation ;  but  I  have 
met  with  several  cases  in  which  there  was  a  redness  or 
erythema  at  the  fourchette.  Usually,  the  hymen  is 
thick  and  voluminous,  and  when  the  finger  is  forced 
through  it,  its  free  border  often  feels  as  resistant  as  if 
bound  by  a  fine  cord  or  wire. 

By  the  term  blepharismus,  or  blepharo-spasmus,  we 
mean  an  involuntary  painful  spasmodic  contraction  of  the 
orbicularis  palpebrarum,  with  great  supersensitiveness, 
or  intolerance  of  light.  By  the  term  laryngismus,  we 
mean  a  spasmodic  contraction  of  the  vocal  apparatus^ 
producing  stridulous  inspiration ;  and,  by  analogy,  I  call 
this  painful  spasmodic  contraction  of  the  mouth  of  the 


VAGINISMUS.  321 

1  presented  a  paper  on  this  subject  to  the  Obstetrical 
Society  of  London  in  December,  1861,*  from  which  I 
will  here  extract  a  few  particulars. 

In  May,  1857,  I  was  called  to  see  a  lady,  aged  forty- 
five  years,  who  was  married  at  twenty,  and  had  been  an 
invalid  ever  since.  Menstruation,  always  painful,  had 
just  ceased.  She  had  great  irritability  of  the  bladder,  a 
sense  of  bearing  down,  and  other  symptoms  of  uterine 
deransrement.  But  to  me  the  most  remarkable  thins:  in 
her  history  was  the  fact  that  she  had  remained  a  virgin 
notwithstanding  a  married  state  of  a  quarter  of  a  cen- 
tury. Some  two  or  three  years  after  marriage  her  phy- 
sician discovered  a  sanguineous  mucous  tubercle  at  the 
meatus  urinarius,  which  he  removed,  and  then  attempted 
to  dilate  the  vagina  with  graduated  bougies,  which  pro- 
duced great  suffering,  without  the  least  permanent  im- 
provement. She  consulted  the  most  eminent  surgeons 
in  the  principal  capitals  of  America,  and  subsequently 
visited  London  and  Paris  for  the  same  purpose  ;  but  no 
one  gave  a  satisfactory  solution  of  the  case,  nor  advised 
anything  more  than  the  bougie  system,  which  had  been 
already  fruitlessly  exhausted. 

Her  nervous  system  was  in  a  deplorable  condition. 
She  was  exceedingly  impressible,  the  slightest  noise 
being  intensely  disagreeable.  She  was  able  to  walk 
only  across  her  room,  but  did  not  often  venture  on  this 
experiment,  being  confined  most  of  the  time  to  her 
couch,  where  she  gave  herself  up  to  unceasing  intellec- 
tual effort. 

I  attempted  to  make  a  vaginal  examination,  but  failed 
completely.     The  slightest  touch  at  the  mouth  of  the 


*  "Obstetrical  Transactions,"  1862,  vol  DL 
21 


322  UTERINE    SURGERY. 

vagina  produced  intense  suffering,  throwing  her  nervous 
■system  into  great  commotion ;  there  was  a  general  mus- 
cular agitation ;  her  whole  frame  shivered  as  if  with  the 
rigours  of  an  intermittent ;  she  shrieked  and  sobbed 
aloud ;  her  eyes  glared  wildly  ;  tears  rolled  down  her 
cheeks,  and  she  presented  altogether  the  most  pitiable 
appearance  of  terror  and  agony.  Notwithstanding  all 
these  outward  involuntary  evidences  of  physical  suffer- 
ing, she  had  the  moral  fortitude  to  hold  herself  on  the 
couch,  and  implored  me  not  to  desist  from  my  efforts  if 
there  was  the  least  hope  of  finding  out  anything  about 
her  inexplicable  condition.  After  pressing  with  all  my 
strength  for  some  moments,  I  succeeded  in  introducing 
the  index  finger  into  the  vagina  up  to  the  second  joint, 
but  no  further.  The  resistance  to  its  passage  was  so 
great,  and  the  vaginal  contraction  so  firm,  as  to  deaden 
the  sensation  of  the  finger,  and  thus  the  examination 
revealed  only  an  insuperable  spasm  of  the  sphincter 
vaginae.  I  candidly  told  her  husband  I  knew  nothing 
whatever  about  the  case,  had  never  seen  or  heard  of 
anything  like  it,  and  therefore  could  promise  nothing. 
However  I  suggested  the  propriety  of  their  going  to 
New  York,  for  further  investigation  under  anaesthesia. 
They  acted  promptly  on  this  suggestion,  and  I  invited 
the  late  Dr.  John  W.  Francis,  Dr.  Emmet,  of  the  Wo- 
man's Hospital,  Professor  Van  Buren,  and  Dr.  Kissam  to 
see  her  with  me.  The  two  latter-named  gentlemen 
assumed  the  responsibility  of  the  etherization.  Pre- 
viously to  the  anaesthesia  I  attempted  to  make  a  vaginal 
examination,  when  the  same  train  of  symptoms  was 
manifested  as  on  the  former  occasion.  But  as  soon  as 
she  was  fully  under  the  influence  of  the  ether,  T  found, 
greatly  to  my  surprise,  the  mouth  of  the  vagina  com- 
pletely relaxed  and  the  vagina  itself  perfectly  normal. 


VAGINISMUS 


323 


It  was  not  large,  but  certainly  quite  as  well  (level()ped 
as  it  ought  to  have  been  at  her  time  of  life  and  undei 
the  circumstances.  The  uterus  was  retroverted,  and 
there  was  a  small  polypoid  excrescence  about  the  size  ol 
a  pea  hanging  from  the  os  tincge.  This  was  removed, 
not  with  the  expectation  of  its  exerting  any  influence  on 
her  peculiar  condition,  but  to  prevent  the  risk  of  its 
future  growth.  I  gave  the  opinion  that  it  was  a  spas- 
modic contraction  of  the  sphincter  vaginae,  resulting 
from  an  irritable  condition  of  the  nerves  of  the  part, 
which  I  could  not  explain.  When  asked  if  it  was  possi- 
ble to  cure  it,  I  said — "  I  do  not  know,  for  the  books 
throw  no  light  on  the  subject ;  but  it  appears  to  me 
that  the  only  rational  treatment  would  be  surgical." 
However  I  declined  to  do  anything,  on  the  ground  that 
an  untried  process  was  not  justifiable  on  one  in  her 
position  in  society,  the  hospital  being  the  legitimate 
field  for  experimental  observation. 

This  case  is  an  exaggerated  example  of  its  class.  I 
have  seen  several  nearly,  but  not  quite,  as  bad.  The 
high  intellectual  endowments  of  this  lady,  her  elegant 
culture  and  fine  social  position,  as  well  as  her  long 
suffering,  all  conspired  to  make  her  case  one  of  much 
thought  and  great  anxiety  to  me  ;  and  it  was  not  easily 
dismissed  from  my  mind.  It  was  the  first  case  of  the 
sort  I  had  ever  seen,  and  I  could  not  help  wondering  if 
it  would  be  the  last.  But  about  fifteen  months  after 
this.  Professor  Pitcher,  of  Detroit,  Michigan,  sent  me 
another  similar  case,  except  that  the  lady  had  been 
married  but  two  years.  She  had  the  same  instinctive 
dread  of  being  touched,  the  same  muscular  agitation 
and  shivering  of  the  whole  frame,  and  the  same  pain 
and  spasm  of  the  sphincter  on  attempting  to  pass  the 
finger  into  the  vagina.     As  this  lady's  husband  threat- 


324  UTERINE  SURGERY. 

eiied  to  obtain  a  divorce,  I  looked  upon  her  case  as  a 
proper  one  for  experiment.  Explaining  to  lier  fully  our 
ignorance  on  the  subject,  I  proposed  a  series  of  experi- 
mental incisions,  which  she  readily  assented  to.  Think- 
ing that  the  division  of  the  irritable  spasmodic  outlet 
was  the  only  rational  opei'ative  procedure,  I  divided  first 
only  the  edges  of  the  hymeneal  membrane  on  each  side 
of  the  fourchette.  There  was  no  relief.  Waiting  for 
the  wounds  to  heal,  I  then  divided  the  parts  again  at 
the  same  points,  but  extending  the  incisions  deeply 
through  the  mucous  membrane  and  through  some  of  the 
fibres  of  the  sphincter  muscle.  This  was  followed  by 
some  improvement ;  she  could  bear  the  introduction  of 
one  finger  without  very  great  pain,  and  could  even 
tolerate  two,  but  it  was  with  considerable  suffering.  I 
now  saw  that  the  hymen  itself  was  the  focus  of  the 
excessive  irritability,  and  I  then  proposed  to  cut  it  out 
entirely,  and  afterwards  to  repeat  the  lateral  incisions  as 
before,  making  them  deeper,  and  rendering  the  dilatation 
permanent  by  the  use  of  a  properly  constructed  bougie. 
By  this  time  the  mother  of  my  patient  came  to  the 
conclusion  that  I  was  experimenting  on  her  daughter. 
I  told  her  it  was  true,  and  attempted  to  justify  the  pro- 
priety of  the  course  when  a  lawsuit  and  a  divorce  were 
in  prospect.  The  mother,  however,  was  inexorable,  and 
unfortunately  removed  her  daughter  from  my  care.  But 
her  improvement  was  so  great  that  I  had  no  doubt  of 
her  ability  to  fulfil  the  duties  of  a  wife  under  some 
difficulties.  The  experience  gained  by  this  case  was  of 
gieat  value  to  me. 

A  few  weeks  afterwards,  January,  1859,  another  case 
fell  into  my  hands.  This  patient  was  the  wife  of  a  clergy- 
man, and  had  been  mai-ried  six  years.  Sexual  intercourse 
was  impossible.    Several  surgeons  had  been  consulted,  but 


VAGINISMUS.  32A 

witliout  any  explanation  of  lier  conclition,  and  of  (iourse 
without  any  relief.  Ou  examination,  I  discovered  a 
sanguineous,  mucous,  painful  tumour  at  the  meatus  urina- 
rius,  and  notwithstanding  the  experience  already  related, 
I  persuaded  myself  that  this  tubercle  was  alone  the 
source  of  all  her  trouble.  It  was  removed,  and  its  seat 
cauterized.  In  due  time  she  returned  home,  but  came 
back  to  me  in  a  few  days  to  report  a  persistence  of  her 
former  sufferings.  On  a  more  minute  examination,  I 
found  it  to  be  in  all  particulars  just  such  a  case  as  those 
previously  related,  but  not  quite  so  intense  in  its  mani- 
festations. The  slisrhtest  touch  with  a  feather  or  with  a 
camel's-hair  pencil  at  the  reduplication  of  the  hymeneal 
membrane  produced  as  severe  suffering  as  if  she  were 
cut  with  a  knife.  While  this  lady  was  under  observa- 
tion (April,  1859),  a  fourth  case  of  the  same  sort  came 
under  my  care,  that  of  a  woman  who  had  been  married 
three  years.  Sexual  intercourse  had  been  imperfectly 
accomplished  a  few  times  during  the  first  few  weeks  after 
marriage.  She  innocently  supposed  that  all  women  had 
to  suffer  as  she  did,  and  tried  to  bear  it ;  but  her  sufferings 
were  so  severe  that  at  last  she  looked  with  the  greatest 
terror  upon  the  approaches  of  her  husband.  At  her 
earnest  entreaties,  he  ceased  all  efforts  at  sexual  inter- 
course, and  they  lived  together  like  brother  and  sister. 
But  at  last  the  mother  of  the  poor  timid  girl  began  to 
wonder  why,  after  three  years  of  married  life,  her 
daughter,  who  seemed  to  be  healthy  and  had  a  healthy 
vigorous  young  husband,  did  not  become  pregnant,  and 
ventured  to  speak  of  her  disappointment ;  whereupon 
the  daughter  hesitatingly  explained  it  all  to  the  mother, 
who  immediately  brought  her  to  see  me,  when  I  found 
precisel}^  the  same  condition  of  things  already  described. 
A  few  weeks  after  this,  Dr.  Hariis,  of  East  Thirtieth 


326  UTERINE  SURGERY. 

Street,  New  York,  sent  me  another  case  (tlie  fifth). 
His  patient  had  been  married  two  and  a  half  yeais,  and 
sexual  intercourse  was  impossible.  I  now  (June  18th, 
1859)  had  three  cases  all  at  one  time  under  observation  ; 
but  to  cut  short  this  long  narrative,  I  may  here  say  that 
they  were  all,  after  many  experiments  and  disappoint- 
ments, perfectly  cured  in  the  f(jllowing  August. 

From  personal  observation  I  can  confidently  assert 
that  I  know  of  no  disease  capable  of  producing  so  much 
uuhappiness  to  both  parties  of  the  marriage  contract, 
and  I  am  happy  to  state  that  I  know  of  no  serious 
trouble  that  can  be  cured  so  easily,  so  safely,  and  so 
certainly. 

Treatment. — The  treatment  consists  in  the  removal 
of  the  hymen,  the  incision  of  the  vaginal  orifice,  and 
subsequent  dilatation.  The  last  is  useless  without  the 
first  two,  but  is  essential  to  easy  and  perfect  success 
with  them.  I  usually  make  two  operations,  but  it  may 
all  be  done  at  once. 

Placing  the  patient  (etherized)  on  the  left  side,  I 
seize  the  hymeneal  membrane  with  a  delicate  pair  of 
forceps  just  at  its  junction  with  the  urethra  on  the  left 
side,  and  putting  it  on  the  stretch,  clip  with  properly 
curved  scissors  till  the  whole  is  removed  in  one  con 
tinuous  piece. 

In  some  cases  the  haemorrhage  requires  a  compress 
of  lint.  In  two  instances  the  bleeding  was  excessive, 
but  easily  checked  with  the  Liq.  Ferri  Persulphatis. 
The  cut  surface  usually  heals  entirely  in  three  or  four 
days,  after  which  the  operation  for  a  radical  cure  may 
be  performed.  Notwithstanding  the  removal  of  the 
thick,  sensitive  hymen,  the  cicatrix  marking  its  original 
place  at  the  mouth  of  the  vagina  is  exceedingly  sensi- 
tive, and  in  some  instances  feels  hard  and  tense,  as  if 


VAGINISMUS.  327 

a  wire  or  small  cord  were  coostrictino:  tlie  outlet.  This 
I  divided  at  various  poiuts  and  in  divers  ways  during 
ray  early  experiments,  and  finally  arrived  at  the  follow- 
ing method,  as  being  the  surest  and  best. 

Place  the  patient  (fully  etherized)  as  for  lithotomy, 
on  the  back ;  pass  the  index  and  middle  fingers  of  the 
left  hand  into  the  vagina,  separate  them  laterally,  so  as 
to  dilate  the  vagina  as  widely  as  possible,  putting  the 
fourchette  on  the  stretch  ;  then  with  a  common  scalpel 
make  a  deep  cut  through  the  vaginal  tissue  on  one  side 
of  the  mesial  line,  bringing  it  from  above  downwards, 
and  terminating  at  the  raphe  of  the  perineum.  This  cut 
forms  one  side  of  a  Y*  Then  pass  the  knife  again  into 
the  vagina,  still  dilating  with  the  fingers  as  before,  and 
cut  in  like  manner  on  the  opposite  side  from  above  down- 
wards, uniting  the  two  incisions  at  or  near  the  raphe, 
and  prolonging  them  quite  to  the  perineal  integument. 
Each  cut  will  be  about  two  inches  lonof,  i.  e.  half  an  inch 
or  more  above  the  edge  of  the  sphincter,  half  an  inch 
over  its  fibres,  and  an  inch  from  its  lower  edge  to  the 
perineal  raphe.  Of  course  this  will  vary  in  different 
subjects  according  to  the  development  of  the  parts  in 
each.  To  perfect  the  cure  it  is  necessary  for  the  patient 
to  v/ear  for  a  time  a  properly  adapted  bougie  or  dilatoi-. 
I  use  a  dilator  made  usually  of  glass,  sometimes  of 
metal  or  ivory.  I  prefer  glass  because  it  is  easily  kept 
clean,  and  being  transparent,  it  is  easy  to  see  the  cut 
surface,  and  indeed  the  whole  vagina,  without  removing 
it.  If  there  is  much  bleedino:,  I  introduce  the  dilator 
at  once ;  but  usually  I  wait  twenty-four  hours,  when  it 
is  worn  one,  two,  three,  or  four  hours  at  once.  Its 
introduction  is  attended  with  a  sense  of  soreness,  but 
with  none  of  the  peculiar  agonizing  sufteriug  so  character- 
istic of  the  original  disease. 


328  UTERINE    SURGERY. 

The  patient  will  generally  wear  the  dilator  two  hours 
in  the  morning  and  two  or  three  hours  in  the  afternoon 
or  evening;  sometimes  for  a  longer  period.  I  have 
known  a  few  who  wore  it  six  or  eis^ht  hours  at  a  time. 
I  have  often  been  astonished  at  the  rapidity  with  which 
the  cuts  sometimes  healed,  the  cure  being  seemingly 
facilitated  by  the  pressure  of  the  glass  tube. 

I  direct  the  dilator  to  be  worn  daily  for  two  or  three 
weeks,  or  longer,  or  till  the  parts  are  entirely  cured  and 
all  sensitiveness  removed. 

The  dilator  is  a  tube  about  three  inches  long,  slightly 
conical,  ojien  at  one  end,  closed  at  the  other,  and  an 
inch  and  a  quarter  or  an  inch  and  a  third  in  diameter 
at  the  largest  part,  near  the  open  or  outer  end. 

There  is  a  depression  or  sulcus  on  one  side  for  the 
urethra  and  neck  of  the  bladder  (fig.  128). 

The  outer  open  end  allows  the  pressure  of  the 
atmosphere  to  assist  in  retaining  it  easily  in  the  vagina. 


Fig.  128. 


When  closed  at  both  ends,  it  is  much  more  difficult  to 
retain  it  m  situ^  even  with  a  well-adjusted  f  bandage. 
The  depression  for  the  urethra  is  very  important,  for  I 
found  that  a  perfectly  round  cylinder,  worn  for  three  or 
four  hours,  always  injured  the  urethra  ;  and,  moreover, 
this  urethral  depression  assists  the  self-retaining  capacity 
of  the  instrument. 

Dr.  Rottenstein,  a  celebrated  American  dentist  in 


VAGINISMUS.  329 

Paris,  has  recently  made  for  me  a  dilator  of  vulcanite, 
which  answers  very  well.  It  is  quite  as  cleanly  as  glass, 
and  is  not  so  liable  to  be  broken. 

While  these  pages  were  going  through  the  press,  I 
had  occasion  to  operate  on  a  lady  fifty-four  years  of 
age,  who  was  married  at  eighteen,  a  widow  at  twenty, 
and  married  again  at  forty.  During  her  first  marriage 
copulation  was  effected  occasionally,  but  it  was  under 
most  trying  circumstances,  and  with  the  most  intense 
suffering.  During  her  last  marriage  it  was  impossible. 
I  found  the  mouth  of  the  vagina  a  little  reddish,  inflamed, 
and  excessively  irritable,  the  slightest  touch  with  a  probe 
producing  intense  agony.  The  finger  could  be  passed 
into  the  vagina,  but  it  caused  great  suffering.  It  was, 
and  had  always  been,  a  well-marked  case  of  vaginismus. 
The  hymen  did  not  present  any  undue  development,  and 
I  simply  incised  the  parts  on  each  side  of  the  middle 
Hue,  through  to  the  verge  of  the  perineum.  The  whole 
vulvar  outlet  was  unnaturally  small,  and  the  incisions 
were  extended  well  through  the  outer  edge  of  the  peri- 
neum. A  glass  dilator  was  worn  three  or  four  hours  a 
day  for  a  month  ;  but  at  the  end  of  this  time  the  mouth 
of  the  vagina  was  just  as  sensitive  and  as  spasmodic  as 
before  the  operation. 

I  now  determined  to  remove  all  the  hypertrophied 
tissue  at  the  fourchette  and  divide  anew  the  parts 
beneath.  "Wishing  to  make  pressure  with  the  dilator 
more  in  the  direction  of  the  fourchette  and  perineum 
than  laterally,  I  had  the  instrument  made  as  repre- 
sented in  fig.  129,  which  seems  to  be  a  great  improve- 
ment on  the  purely  cylindrical  instrument.  Instead  of 
expanding  the  outer  end  of  the  dilator,  as  seen  in  fig. 
128,  it  is  often  necessary  to  roll  its  border  inwards  to 
prevent  pressure  on  the  labia. 


330  UTERINE    SURGERY. 

In  some  instances  the  instrument  is  too  long,  and 
produces  pain  by  pressure  against  the  cervix  uteri.  It 
will  then  be  necessary  to  make  it  shorter.  The  down- 
ward curvature  of  the  conical  extremity,  as  here  repre- 
sented, prevents  it  from  striking  against  and  hurting  the 
uterus. 


Pig.  129. 

I  have  now  operated  on  thirty-nine  cases  of  vaginis- 
mus, and  in  every  instance  with  perfect  success.  Many 
of  these  were  complicated  with  other  causes  of  a  sterile 
condition,  such  as  painful  menstruation,  contracted  os, 
conical  cervix,  fibroid  tumour,  or  malposition.  But 
notwithstanding  this,  six  conceptions  have  followed  the 
operation.  Some  others,  from  whom  I  have  not  heard, 
have  probably  conceived,  and  a  few  more  of  them  will 
almost  certainly  do  so.  They  have  usually  been  so  well 
satisfied  with  the  removal  of  the  vaginismus  that  they 
did  not  care  to  undergo  any  further  treatment  for  a 
condition  that  might  be  attended  to  at  a  more  conve- 
nient season. 

Churchill,  Debout,  and  some  others,  have  thought 
that  a  state  of  vaginismus  could  hardly  exist  long  where 
the  husband  possessed  strong  copulative  capacity ;  but 
I  am  sure  this  is  an  error;  for  I  have  seen  several 
instances  in  which  the  virile  power  of  the  husband  was 
unusually  strong,  but   yet  powerless   to  overcome  the 


VAGINISMUS.  331 

obstruction  ;  and  I  liave  seen  two  cases  that  had  been 
subjected  to  the  most  powerful  means  of  dilatation,  long 
continued,  and  to  a  great  degree ;  and  yet  the  spasmodic 
action  remained  just  the  same.  One  of  these  has  now 
been  married  eighteen  years ;  and  for  six  months  she 
submitted,  many  years  ago,  to  the  torture  of  a  tri valve 
dilator  passed  into  the  vagina,  and  opened  to  its  widest 
extent :  and  all  for  no  purpose.  So  great  was  her  dread 
of  the  peculiar  pain  of  this  affection  that  her  husband 
could  not  persuade  her  to  submit  to  an  operation  at  my 
hands,  and  thus  she  remains  as  at  her  marriage. 

1  have  operated  on  those  who  had  been  married 
seventeen  years,  fifteen  years,  twelve  years,  and  so  on 
down  to  two  years.  In  a  few  instances  sexual  inter- 
course had  been  imperfectly  accomplished,  but  in  the 
great  majority  of  cases  it  had  never  been  consummated. 
In  two  instances,  the  husbands,  though  young  and 
vigorous,  were  so  excitable  that  the  semen  was  quickly 
lost,  but  in  both  of  these  cases  the  vaginismus  was  so 
inveterate  that  I  am  sure  it  would  have  persisted  even 
under  other  circumstances. 

Dr.  T.  G.  Thomas,  of  New  York,  gave  me  the  history 
of  a  case  in  which  a  physician  etherized  his  patient,  and 
then  left  her  to  her  husband,  who  cohabited  with  her 
with  the  greatest  >  ease  ;  but  he  could  not  repeat  the  act 
when  she  was  not  etherized.  Fortunately,  the  period 
was  well  chosen,  for  this  single  act  of  copulation  was 
followed  by  conception.  I  have  known  other  cases 
where  conception  occurred  without  the  introduction  of 
the  virile  organ.  The  seminal  fluid  was  lost  at  the 
mouth  of  the  vagina,  and  a  little  was  doubtless  injected 
through  the  hymeneal  opening,  and  made  its  way  to  the 
cavity  of  the  uterus. 

Sir  Joseph  Olliffe  has  given  me  the  history  of  a  case 


332  UTERINE  SURGERY. 

of  tills  sort,  where  conception  occurred  without  pene- 
tration of  the  hymen.  It  is  not  uncommon  to  hear  of  a 
pregnancy  at  full  term  where  the  hymen  is  unruptured. 
I  presume  that  all  such  cases  are  examples  of  vaginis- 
mus. 

Many  surgeons  are  of  opinion,  since  I  first  described 
this  affection,  that  it  is  sufficient  to  forcibly  dilate  the 
mouth  of  the  vagina,  or  to  incise  it,  and  then  use  the 
dilator ;  but  I  am  well  satisfied  that  the  plan  of  remov- 
ing the  hymen  entirely  is  much  the  best ;  not  only  of 
removing  the  hymen,  but  of  removing  any  and  every 
super-sensitive  point. 

In  1863,  I  saw  a  lady  with  vaginismus  who  had  been 
married  six  years,  and  during  all  this  time  she  had  sub- 
mitted to  sexual  congress,  notwithstanding  the  intense 
suffering  that  it  occasioned  her.  I  found  the  hymen 
unbroken,  but  dilatable.  It  was  exceedingly  tough, 
and  would  stretch  almost  like  an  india-rubber  string.  I 
used  my  sj^eculum,  pulling  the  perineum  far  back 
towards  the  coccyx,  w^hich  opened  the  mouth  of  the 
vagina  sufficiently  for  any  purpose.  This  w^as  attended 
with  great  pain,  but  the  hymen  did  not  give  way.  I 
excised  it,  divided  the  fourchette,  and  used  the  dilator 
till  the  parts  were  healed.  She  went  home,  but  return- 
ed in  a  few  days  to  say  that  sexual  intercourse  was  as 
unbearable  as  ever.  On  a  minute  examination,  I  found 
a  small  tubercle  of  indurated  tissue  on  the  ris^ht  side  of 
the  mouth  of  the  vagina,  not  larger  than  a  grain  of 
wheat.  It  was  very  sensitive  even  to  the  touch  of  a 
camel's-hair  pencil.  It  was  hooked  up  with  a  tenacu- 
lum, and  cut  out,  and  immediately  the  peculiar  sensitive- 
ness of  the  part  was  gone.  The  relief  afforded  was  as 
sudden  as  it  would  have  been  by  the  removal  of  a  sub- 
cutaneous neuromatous  tumour.     Indeed  it  has  always 


VAGINISMUS.  333 

appeared  to  me  that  the  symptoms  of  vaginismus  were 
neuromatous.  However,  my  friend  Professor  Alonzo 
Clark,  one  of  the  ablest  pathologists  in  my  own  country, 
has  frequently  examined  the  vaginismus  hymen  for  me, 
and  could  not  find  any  enlarged  nerve  filaments  running 
through  it. 

The  case  above  related  was  cured  by  the  slight  ope- 
ration performed  the  second  time. 

Fig.  130  represents  the  exact  size  of  the  hymen  in 
this  case,  immediately  after  its  removal.  The  indenta- 
tion on  its  left  side  corresponds  precisely  with  the  seat 
of  the  little  tubercle  removed  at  the  second  operation, 
and  which  was  doubtless  the  result  of  the  imperfect 
excision  of  the  thickened  base  of  the 
hymeneal  membrane.  This  case  proves 
very  conclusively  how  impoi-tant  it  is  to 
exsect  the  hymen  in  its  totality ;  for  here 
a  small  point  was  left  which  produced  great 
sufi^srins:  afterwards.  But  to  show  to  a 
greater  certainty  the  propriety  of  this 
course  of  treatment,  I  will  here  relate  a 
most  remarkable  case  that  fell  under  my  observation  a 
few  years  ago. 

A  lady,  aged  thirty,  was  married  at  twenty-one. 
Vigorous  efix)rts  at  copulation  were  made  fruitlessly  for 
five  or  six  weeks.  The  husband  and  wife  were  both 
young  and  of  course  ignorant  on  the  subject,  and  were 
not  surprised  that  there  was  difficulty  at  the  beginning ; 
but  soon  they  l)egan  to  debate  the  point  of  asking  medi- 
cal advice.  At  last  the  wife  became  worn  out  with  the 
oft-repeated  and  painful  efforts  at  coition,  and  agreed  to 
a  consultation. 

The  family  physician  was  called,  who  supposed  that 
there  must  be  some  unusual  degree  of  disproportion  in 


334  UTERINE    SURGERY. 

the  relative  development  of  their  respective  genital 
organs,  and  advised  sexual  intercourse  while  the  wife 
was  etherized.  This  was  soon  done  and  the  wife  knew 
nothing  of  it.  But  when  the  act  was  attempted  the 
next  day  and  the  next,  it  was  found  to  be  utterly  impos- 
sible. After  a  week's  fruitless  trial,  the  physician  was 
sent  for  again,  and  again  she  was  etherized,  and  coition 
effected  with  the  greatest  ease.  But  it  was  subsequently 
impossible  when  she  was  not  etherized.  The  husband 
was  tall,  athletic,  and  muscular;  says  he  is  not  subject 
to  hasty  ejaculation,  and  possesses  extraordinary  copula- 
tive powers.  So  that  it  w^as  not  the  fault  of  the  husband 
that  the  vaginismus  did  not  yield  to  penetration  and 
dilatation.  But  the  subsequent  history  of  this  interest- 
ing case  bears  still  more  strongly  on  this  point.  Suffice 
it  to  say  that  it  became  the  business  of  the  physician  to 
repair  regularly  to  the  residence  of  this  couple  two  or 
three  times  a  week  to  etherize  the  poor  wife  for  the 
purpose  above  alluded  to.  They  persevered,  hoping 
that  she  would  become  pregnant  and  that  delivery  would 
cure  her.  This  etherization  was  continued  for  a  year, 
when  conception  occurred.  But  during  the  whole  period 
of  utero-gestation,  etherization  was  necessary  to  coition. 
After  the  birth  of  the  child  there  were  a  few  copula- 
tions without  ether,  but  it  was  exceedingly  painful,  and 
soon  the  pain  became  so  severe  that  they  were  compel- 
led to  resort  to  ether  again.  At  the  end  of  another  year 
of  ethereal  copulation,  there  Avas  another  conception, 
which  resulted  in  an  abortion  at  the  third  month.  After 
this  she  was  etherized  constantly  for  nearly  another 
year,  when  at  last  they  saw  no  hope  of  a  cure,  and  be- 
coming alarmed  at  the  frequent  repetition  of  the  anaes- 
thesia, they  concluded  to  give  it  up  altogether.  And 
when  they  consulted  rae  there  had  been  no  effort  at 


VAGINISMUS.  335 

copulation  for  three  or  four  years.  They  had  consul  tec 
other  physicians  in  the  mean  time,  but  no  one  explained 
the  case  or  proposed  a  remedy. 

The  mouth  of  the  vagina  was  barely  large  enough  to 
admit  the  index  finger.  The  seat  of  the  hymen  was 
red,  inflamed,  thickened,  indurated,  and  exceedingly 
sensitive  to  the  slightest  touch  with  the  finger,  a  probe, 
or  a  feather.  There  was  a  reddish  blotch,  about  the 
size  of  half  a  split  pea,  at  the  orifice  of  each  vulvo- 
vaginal gland.  The  perineum  had  been  lacerated 
down  to  the  fibres  of  the  sphincter  muscle,  and  now  a 
tense,  inelastic  inodular  band  extended  across  the 
fourchette,  and  was  lost  in  the  thickened  tissue  occupy- 
ing the  original  seat  of  the  hymen.  Tliis  entire  ring 
was  quite  as  sensitive  to  a  gentle  touch  as  the  most 
marked  case  of  vaginismus  could  be ;  indeed,  it  was  a 
vaginismus  now,  notwithstanding  the  fact  that  coition 
had  been  accomplished  scores,  nay,  hundreds  of  times, 
and  that  a  labour  at  full  term  and  a  miscarriage  had 
also  occurred  to  break  up  the  morbid  condition,  if  it 
could  be  done  by  the  mere  mechanical  action  of  dis- 
tension. I  would  not  pretend  to  deny  that  we  can  dilate 
a  case  of  vaginismus  so  as  to  permit  sexual  intercourse, 
but  in  most  of  the  cases  so  treated  the  act  is  very  painful. 
In  every  case  that  I  have  operated  upon  by  removal  of 
the  hymen,  and  then  by  division  and  dilatation,  sexual 
intercourse  has  been  accomplished  without  pain. 

The  course  to  be  pursued  in  the  case  we  are  de- 
scribing was  very  plain,  viz.,  to  remove  the  whole  ring 
of  thickened  tissue  that  encircled  the  mouth  of  the 
vagina,  and  particularly  the  cicatricial  portion  at  the 
fourchette.  This  was  done,  an'd  then  the  septum 
between  the  fourchette  and  the  rectum  was  divided  on 
each   side,   down    tiirough  the  fibres   of  the  sphincter 


336  UTERINE  SURGERY. 

muscle  and  the  fourcliette  to  the  perim>al  raphe.  This 
left  a  very  thin  partition  between  the  two  outlets. 
After  this  a  glass  vaginal  dilator  was  introduced,  and 
worn  almost  constantly.  A  larger  one  was  used  in  a 
day  or  two,  and  in  a  fortnight  sexual  intercourse  was 
accomplished  for  the  first  time  without  pain.  Where 
there  is  cicatricial  tissue,  as  in  this  case,  there  is  danger 
of  a  relapse,  and  hence  greater  necessity  for  a  prolonged 
use  of  the  dilator.  This  remarkable  case  presents 
many  points  of  interest,  not  the  least  of  which  is  the 
fact  that  the  two  conceptions  took  place  while  she  was 
in  a  state  of  complete  anaesthesia. 

3.  Atresia  Vagina. — This,  of  coui-se,  forms  an 
obstacle  to  the  reception  of  the  seminal  fluid.  It  may 
be  congenital  or  accidental, — more  frequently  the  latter, 
and  oftener  the  result  of  tedious  labour,  followed  by 
sloughing.  The  records  of  the  Woman's  Hospital 
present  a  number  of  cases  of  atresia,  a  few  of  which  will 
serve  as  examples. 

I  have  seen  but  one  case  that  might  be  called  con- 
genital ;  and  that  was  in  a  young  girl  aged  eighteen,  who 
entered  the  Hospital  in  October,  1857,  complaining  of 
great  pain  every  month  without  ever  having  had  the 
slightest  show.  She  had  taken  aloetic  purgatives  and 
other  emmenas^oo-ues  without  benefit. 

On  examination,  a  rounded  tumour,  half  as  large  as 
a  foetal  head,  supposed  to  be  the  uterus,  could  be  felt  in 
the  hypogastrium.  The  finger  passed  through  the 
hymen,  which  was  very  rigid,  detected  a  hard  inelastic 
tumour,  three-quarters  of  an  inch  beyond  it,  the  vagina 
seemingly  ending  there  in  a  cul-de-sac.  By  passing 
the  finger  into  the  rectum,  it  came  in  contact  with  the 
tumour  felt  through  the  vagina,  and  which  appeared 


ATRESIA  YAGIN^.. 


oo  i 


to  be  the  upper  two-thirds  of  the  vagina  distended 
with  something  hard  and  inelastic,  and  continuous 
with  the  tumour  that  rose  above  the  symphysis  pubis. 

The  rational  symptoms  and  anatomical  relations  all 
pointed  -to  retention  of  the  menses  by  occlusion  of  tbe 
lower  third  of  the  vagina.  But  to  the  sense  of  touch 
per  rectum,  with  supra-pubic  pressure  or  palpation,  it 
felt  exactly  like  an  osteo-fibroid  tumour.  The  lower  or 
vaginal  part  of  the  tumour  was  quite  as  unyielding  to 
pressure  as  the  upper  part  or  uterine  portion. 

Fig.    131    represents    the    relations    of    the    utero- 


Fia.  131. 

vaginal  tumour,  formed  by  the  occlusion  of  the  walls 
of  the  vagina.  A  very  small  puncture  was  made  into 
the  tumour,  through  the  occluded  vagina  where  the 
tissue  seemed  to  be  about  a  half  inch  thick.  The 
fluid  gradually  oozed  away.  There  was  no  constitu- 
tional disturbance;  and  the  patient  experienced  only 
relief  from  its  evacuation.  When  the  uterus  was 
found  diminished  to  its  normal  size,  we  ventured  to 
enlarge  the  opening  sufficiently  to  pass  the  index 
finger   up   to   the    os   tincse,   and   we    kept   it    dilated 

22 


338  UTERINE  SURGERT. 

to  tills  moderate  extent  till  tlie  divided  parts  were 
covered  with  mucous  membrane.  The  os  and  cervix 
uteri  presented  a  remarkable  state  of  granular  erosion, 
extending  over  the  adjacent  portion  of  vagina,  and 
giving  rise  to  a  profuse  albuminoid  leucorrhoeal  dis- 
charge, which  yielded  to  appropriate  treatment  in  the 
course  of  a  month.  The  next  menstruation  was  normal 
and  she  left  the  Hospital  with  the  vagina  slightly 
narrowed  at  the  original  seat  of  occlusion. 

This  case  might  have  been  congenital,  or  the  oppos- 
injT  sides  of  the  vaccina  mis^ht  have  formed  adhesions  bv 
inflammatory  action  during  childhood. 

We  have  seen  at  the  Woman's  Hospital  atresia  in 
great  variety  from  sloughing  of  the  soft  parts  and 
consequent  cicatrization.  Sometimes  the  mouth  of  the 
vagina  is  closed,  or  nearly  so ;  again,  we  may  have  a 
contraction  and  closure  of  its  middle  portion ;  and, 
again,  the  upper  part  of  the  vagina  and  the  neck  of  the 
uterus  may  be  agglutinated  together  in  one  dense  mass 
of  fibro-cellular  tissue,  while  we  may  occasionally  find  a 
complete  obliteration  of  this  canal,  from  the  neck  of 
the  bladder  quite  to  the  os  tiucse.  In  all  cases  the 
treatment  is  the  same ;  viz.,  to  restore  the  canal,  if 
possible,  and  to  keep  it  open,  by  the  use  of  the  glass 
dilator,  till  the  newly  exposed  surfaces  become  covered 
with  mucous  membrane.  In  some  instances  this  will 
be  done  in  three  or  four  weeks.  The  constant  wearing 
of  the  dilator  greatly  facilitates  the  healing  of  the 
raw  surfaces  and  the  conversion  of  mere  cellular  into 
mucous  tissue.  There  is  always  such  a  tendency  to 
contraction  that  I  have  directed  the  dilator  to  be  used 
every  day  for  a  long  period  of  time. 

I  have  seen  a  great  many  cases  of  occlusion  of  the 
vaginal   outlet,  where  there  was    an    opening  perhaps 


ATRESIA  YAGIN^.  339 

not  Lirger  than  a  small  probe  for  the  passage  of  the 
raenstrual  flow.  I  have  seen  several  in  which  it  was 
impossible  to  find  this  small  opening  till  the  occurrence 
of  the  flow  indicated  it.  From  these  I  will  select  but 
one  to  'illustrate  the  treatment.  A  lady,  forty-six 
years  old,  was  placed  under  my  care  in  April,  1858,  to 
be  treated  for  atresia.  She  was  married  at  fourteen  ; 
became  a  mother  at  fifteen ;  labour  tedious ;  head 
impacted ;  delivery  instrumental ;  child  still-born ; 
sloughing  of  soft  parts  ;  slow  recovery  ;  atresia  vaginae  ; 
sexual  intercourse  impossible  afterwards.  Eminent 
surgeons  were  consulted,  amongst  others  the  distin- 
guished Drs.  Physic  and  Dewees,  of  Philadelphia,  in 
1828.  Nothing  was  done.  No  attempt  even  was  ever 
made  to  open  the  passage.  In  a  few  years  afterwards 
her  husband  died.  Strange  as  it  may  seem,  this 
lady  married  again  in  three  years.  In  three  years 
more  she  was  a  widow  for  the  second  time.  But  the 
most  unaccountable  thing  is,  that  she  married  again, 
after  I'emaining  a  widow  for  nearly  eighteen  years  and 
knowing  at  the  same  time  that  she  had  had  perfect 
occlusion  of  the  vagina  for  nearly  thirty  years.  She 
had  been  married  the  third  time  about  twelve  months 
when  I  saw  her.  The  mouth  of  the  vaofina  was  sealed 
up,  as  it  were,  by  a  cartilaginous  barrier,  quite  un- 
yielding to  the  strongest  pressure.  But  there  was  a 
small  valvular  opening  through  which  the  menses  made 
their  exit. 

This  little  opening  barely  admitted  a  small  probe ; 
but  this  could  be  passed  the  whole  depth  of  the  vagina, 
and  its  point  could  be  felt  by  the  finger  in  the  rectum 
depressing  the  recto-vaginal  septum,  as  it  was  pushed 
onwards  to  the  os  tincse.  Menstruation  was  normal, 
and   the  uterus,  of  natural  size,  was  in  proper  position. 


340  UTERINE    SURGERY. 

The  vagina  was  normal  above  the  point  of  occlusion, 
which  was  a  little  anterior  to  the  neck  of  the  bladder, 
as  shown  by  fig.  132. 

This  case  was  operated  on  in  June,  1858,  the  late 
Drs.  V.  Mott  and  John  W.  Francis,  with  Dr.  Emmet, 
assisting.  A  small  blunt-pointed  bistoury  was  passed 
through   the   little    opening   into   the   vagina,  and  the 

gristly  structure  was  divided 
from  side  to  side,  and  then  the 
blade  of  the  knife  was  turned 
downwards  and  backwards, 
cutting  outwards,  parallel,  as 
it  were,  with  the  ascending 
ischial  ramus,  first  on  the  i-ight 
and  then  on  the  left,  keeping 
Fig.  132.  lY^Q  index  finger  in  the  rectum, 

to  avoid  making  a  recto-vaginal  fistula. 

In  this  way  the  mouth  of  the  vagina  was  made  quite 
large  enough,  and  when  the  finger  was  passed  in,  it 
was  found  to  be  sufficiently  capacious  above.  The  glass 
dilator  was  introduced,  and  I  had  the  happiness  of 
sending  this  lady  away  in  the  course  of  a  mouth  perfectly 
fitted  for  the  married  life. 

I  directed  her  to  wear  the  instrument  a  while  every 
day  for  an  indefinite  period,  to  guard  against  the  com- 
mon accident  of  relapse 

I  might  relate  many  more  very  curious  and  interesting 
cases  illustrating  this  point,  but  I  forbeai-,  as  enough 
has  been  said  to  establish  the  principles  that  are  to  guide 
us  in  practice. 

4.  CoNGEisriTAL  Abseistce  of  the  Vages'a. — I  have 
seen  five  cases  of  congenital  absence  of  the  vagina, 
and  in  all   of  them   there    was   no   uterus.       One  of 


ABSENTIA  VAGINA.  341 

these,  shown  to  me  by  Dr.  Tivingston,  of  New  York, 
had  been  married  seven  or  eight  years,  She  was  mar- 
ried young,  and,  of  course,  had  no  idea  of  her  peculiar 
condition.  The  labia  were  normally  developed,  and 
the  membranous  tissue  between  the  meatus  urinarius 
and  the  fourchette  had  by  constant  use  been  pushed 
up  between  the  base  of  the  bladder  and  the  rectum 
till  it  was  developed  into  a  blind  pouch,  into  which 
the  finger  could  be  passed  to  the  depth  of  nearly 
two  inches.  • 

As  it  would  serve  no  practical  purpose  to  dilate  on 
this  subject,  I  shall  leave  it  here,  simply  saying  that 
the  diagnosis  in  such  cases  is  easy  enough  with  a  finger 
in  the  rectum,  and  a  sound  in  the  bladder,  alternating 
the  latter  with  supra-pubic  pressure. 

At  the  beginning  of  this  section,  I  said  that  "  the 
vagina  must  be  capable  of  receiving  and  of  retaining 
the  spermatic  fluid." 

HavinsT  now  considered  such  obstacles  as  would 
prevent  the  deposit  of  the  seminal  fluid  in  the  vagina, 
we  may  turn  to  such  conditions  as  prevent  its  retention 
there  when  once  introduced. 

It  has  only  been  about  three  or  four  years  since  I 
found  out  that' some  vaginas  would  not  for  a  moment 
hold  a  drop  of  semen. 

There  are  no  two  vaginas  exactly  alike.  They  difi'er 
in  length,  in  their  various  diameters,  in  their  relations 
with  the  bladder  and  rectum,  in  their  course  with 
regard  to  the  pelvian  axes,  and  in  their  relation  with 
the  axis  of  the  uterus.  They  sometimes  refuse  to  retain 
the  semen  when  they  are  very  capacious ;  again,  when 
they  are  too  short.  In  this  last  instance,  there  will 
probably  be  found  a  disproportion  between  the  sizes 
of  the  respective  genital  organs  of  the  two  sexes. 


342  UTERINE  SURGERY. 

A  young  woman,  married  five  years,  without  issue 
consulted  me  on  account  of  her  sterility.  The  cervix 
was  rather  indurated ;  the  os  was  small.  I  cut  it 
open,  and  the  os  afterwards  presented  (juite  a  normal 
appearance.  As  there  v/as  nothing  otherwise  ab- 
normal about  the  uterus,  I  told  her  she  would  almost 
certainly  conceive  in  four  or  five  months.  She 
patiently  waited  eighteen  months,  and  then  came  to 
me  again  in  despair.  The  condition  of  the  uterus 
was  now  all  that  I  could  have  wished  it.  to  be ;  but 
the  vagina,  as  before  said,  was  rather  short.  For 
the  first  time  I  now  suspected  that  perhaps  the  fault 
lay  here.  I  requested  her  to  come  to  me  at  some  early 
day,  two  or  three  hours  after  sexual  intercourse.  She 
came  the  next  morning.  I  did  not  find  any  signs  of 
spermatozoa  in  the  mucus  of  the  vagina,  or  in  that  of 
the  cervix  uteri.  I  then  began  to  suspect  that  the  fault 
lay  with  her  strong,  vigorous  husband.  I  asked  her  if 
she  seemed  to  retain  anything  after  coition.  She  said 
it  all  appeared  to  pass  off  instantly.  In  such  a  case, 
all  false  delicacy  must  be  laid  aside  ;  it  is  a  matter  of 
the  gravest  scientific  importance,  and  must  be  treated 
as  such. 

I  told  her  and  her  husband  that  I  must  see  her  just 
after  sexual  intercourse.  The  time  was  appointed ;  I 
was  at  the  house,  and  in  four  or  five  minutes  after  the 
act  I  saw  my  patient ;  and  the  vagina  did  not  contain 
a  drop  of  semen,  but  it  was  on  her  person  and  napkin 
in  the  greatest  quantity.  The  microscope  showed  that 
it  was  perfectl}'"  normal.  What  was  to  be  done  ?  The 
vagina  was  short — too  short;  it  could  not  be  made 
longer.  When  the  finger  was  pushed  forcibly  against 
the  posterior  cul-de-sac,  in  the  direction  of  the  dotted 
line    »,    fig.    133,    it    yielded    to    the    pressure,    and 


SHORT  VAGINA.  343 

as  the  finger  was  withdrawn,  the  cul-de-sac  sprang 
forward,  almost  as  if  it  were  made  of  a  thin  sheet  of 
India-rubber.  This  reaction  of  the  distended  vagina 
evidently  ejected  all  the  semen  that  did  not  at  once 
regurgitate  in  the  very  act  of  ejaculation.  Of  course 
the  remedy  was  self-suggestive.  As  we  could  do  no- 
thing to  change  the  size  or  form  of  the  vagina,  we  had 
only  to  order  what  was  so  evidently  indicated — some- 
thing to  prevent  the  forcible  impingement  of  the  male 
organ  against  the  posterior  cul-de-sac.  This  had  the 
desired  effect ;  the  semen  in  sufficient  quantities  was 
retained,  and  conception  occurred  in  thi'ee  months, 
after  a  sterile  marriage  of  nearly  seven  years.  I  now 
think  it  probable  that  the  operation  performed  on  the 
cervix  uteri  was  not  at  all  necessary ;  for  never  till  I 
saw  this  case  had  I  the  remotest  idea  of  such  a  state 
of  things  as  I  have  here  described. 

Fig.  133  would  represent  about  the  relations  of  the 
vagina   and   uterus   in    the    case 
described  above. 

But  it  must  not  be  inferred 
that  all  short  vaginas  are  neces- 
sarily associated  with  a  sterile 
condition.  I  have  seen  several 
cases  in  which  the  vagina  had 
been  almost  wholly  destroyed  by 

the  sloughing  process,  and  in  which  the  neck  of  the 
uterus  had  also  sloughed  away  to  a  great  extent : 
where,  in  fact,  the  vagina  was  not  more  than  two 
inches  deep,  and  yet  conception  occurred  with  the 
greatest  facility ;  but  in  every  one  of  these  cases  the 
upper  part  of  the  vagina  was  fixed  with  the  o]ien  os 
presenting  at  its  bottom  ;  it  was  unyielding,  inelastic, 
did  not  give  before  pressure,  and,  of  course,  did  not 


3J.4  UTERINE    SURGERY. 

rebound  on  its  removal.  Thus  it  was  possible  for  th* 
semen  to  enter  at  once  into  the  canal  of  the  cervix. 

Amongst  several  cases  of  this  sort,  I  now  call  to 
mind  one  of  vesico-vaginal  fistula,  sent  to  the  Woman's 
Hospital,  in  1857,  by  Dr.  Dimond  of  Auburn,  New 
York,  in  which  almost  the  whole  anterior  wall  of  the 
vagina,  a  large  part  of  the  cervix,  and  the  posterior 
cul-de-sac,  and  a  large  portion  of  the  posterior  wall 
of  the  vagina,  were  lost.  There  was  but  a  small  strip 
of  the  anterior  wall,  just  at  the  neck  of  the  bladder ; 
the  fistulous  opening  was  two  inches  wide,  reaching 
from  one  pubic  ramus  across  to  the  other,  through 
which  the  inverted  fundus  of  the  bladder  fell  into  the 
vagina,  presenting  at  its  posterior  border  the  open 
mouths  of  the  ureters,  from  which  we  could  see  the 
urine  passing  off  as  it  was  secreted.  This  case  was 
cured,  but  the  vagina  was  not  more  than  two  inches 
deep.  I  had  but  little  thought  that  she  would  ever 
conceive  again;  but  in  ten  months  after  returning  home 
she  became  a  mother;  and  again,  in  about  fifteen 
months  after  this,  she  gave  birth  to  twins.  In  four 
other  cases  like  this,  the  vagina  was  quite  as  short,  and 
in  all  it  was  fixed  and  inelastic  at  its  upper  part ;  and 
in  all,  the  intra-vagiual  portion  of  the  cervix  uteri  had 
been  destroyed  by  the  sloughing  process,  and  the  03 
presented  itself  as  a  little  gaping  slit  in  the  centre  of 
the  fibrous  structure  that  formed  the  upper  boundary 
of  the  vagina,  which  stretched  aci'oss  the  pelvis  like 
a  cord  of  cartilage. 

In  all  these  cases  but  one,  the  shortening  of  the 
vagina  tilted  the  fundus  uteri  backwards,  and  placed  the 
axis  of  the  uterus  in  a  direct  line  with  that  of  the  vagi- 
na, so  that  the  meatus  urethrse  must,  at  the  moment  of 
ejaculation,  have  been  in  direct  contact,  and  in  a  straight 


VAGIXA— NON-RETAINING. 


845 


line  with  the  open  end  of  the  canal  of  the  cervix  uteri. 
I  have  seen  many  sterile  vi^ombs,  where  I  thought  the 
sterile  condition  could  be  overcome  if  it  were  possible 
to  imitate  artificially  the  unfortunate  state  of  things  here 
produced  accidentally,  i.  6.,  fixing  immovably  the  open 
OS  in  a  direct  line  with  the  ejaculative  force.  This 
would  lead  me  now  to  enquire  into  the  rationale  of 
the  entrance  of  the  semen  into  the  cavity  of  the  uterus ; 
but  I  shall  leave  this  for  the  next  section. 

But  sometimes  the  vagina  does  not  retain  the  semen 
even  when  it  is  of  large  proportions.  When  this  is  the 
case  we  almost  always  find  the  uterus  retro  verted. 


Fig.  131. 


I  have  now  but  little  doubt  that,  in  many  cases  of 
retroversion,  in  which  I  have  seen  pregnancy  follow  the 
rectification  of  the  malposition,  thestei'ile  state  was  due 
to  the  fact  that  the  vamua  did  not  retain  the  semen. 


346  UTERINE    SURGERY. 

I  do  not  mean  to  say  that  in  all  cases  of  retroversion 
the  semen  is  not  retained  ;  far  from  it ;  for  I  know  that 
it  is  often  retained  in  ample  quantities,  in  even  the 
worst  cases  of  retroflexion,  such  as  that  shown  in  fig, 
134. 

The  philosophy  of  this  is  plain  enough ;  for  the 
vaofina  is  here  almost  in  its  normal  relations,  with  what 
should  be  the  proper  axis  of  the  uterus,  although  this 
is  flexed  out  of  its  normal  position.  The  uterine  mal- 
position that  is  most  unfavourable  to  the  retention  of 
the  semen  by  the  vagina  is  that  of  retroversion,  with 
the  OS  tincse  lying  close  up  behind  the  inner  face  of  the 
pubes,  and  the  fundus,  of  course,  thrown  backwards 
below  the  level  of  the  vaginal  axis.  I  made  this  discov- 
ery of  the  ejecting  power  of  the  vagina,  where  there  is 
retroversion,  only  within  the  last  few  years.  It  occurred 
in  this  way.  A  sterile  patient,  in  good  general  health, 
had  painful  menstruation,  a  contracted  os,  and  a  retro- 
verted  uterus.  The  indications  were  to  enlarge  the  os 
and  to  rectify  the  malposition.  Accordingly  I  cut  open 
the  OS  and  cervix,  and  then,  wishing  to  see  if  the  semen 
entered  the  cervix,  I  directed  her  to  come  to  me  some 
mornino;  after  sexual  intercourse.  She  did  so,  but  I 
found  no  traces  of  spermatozoa. 

I  then  said,  "  I  must  see  you  soon  after  the  act  of 
coition  ;"  and  told  her  to  remain  quietly,  in  the  horizon- 
tal position,  till  I  should  arrive.  I  saw  her  in  six  or 
eight  minutes  afterwards,  and  there  was  not  a  vestige 
of  semen  in  the  vagina,  but  it  was  found  in  the  greatest 
abundance  outside  and  on  the  napkins.  The  vagina 
was  very  capacious,  far  above  the  average  size ;  and  I 
could  hardly  believe  my  senses  when  I  found  that  it 
contained  nothing:.  It  was  then  arrano'ed  that  I  should 
see  my  patient  in  fifty  or  sixty  seconds  after  coition,  and 


VAGINA — NON-RETAINING. 


347 


I  found  precisely  the  same  state  of  things,  viz.,  not  a 
sign  of  semen  in  the  vagina.  Now,  let  us  see  why  this 
was  so.  But  first  it  might  have  been  supposed  that  it 
was  due  to  hasty  ejaculation.  Proper  inquiry  settled 
that  cpestion  in  the  negative  by  the  evidence  of  both 
man  and  wife.  Why,  then,  was  there  no  semen  in  this 
very  capacious  vagina  immediately  after  a  normal  copu- 
lation ?  Let  us  look  at  its  anatomical  relations.  The 
uterus  was  retroverted,  but  anteflected ;  the  cervix  was 
long  and  pointed,  and  rested  against  the  urethra;  the 
body  of  the  uterus  was  somewhat  hypertrophied  ;  the 
.anterior  wall  of  the  vagina  rather  short,  in  consequence 


...<5 

Fia.  135. 

of  long  error  of  position ;  the  vagina  was  otherwise  very 
large,  and  the  perineum  relaxed.  The  finger  carried  to 
the  bottom  of  the  vagina,  at  its  reduplication,  a^  fig. 
135,  could  push  this  back  towards  the  hollow  of  the 
sacrum  relatively  as  far  as  hj  this  would  necessarily 
throw  the  fundus  upwards;  the  withdrawal  of  tht 
finger  would  let  it  fall  down  again,  but  its  momentum 
would  carry  it  a  little  lower  than  the  point  at  which  it 
rested  in  equilibrio.  There  was  nothing  easier  of  de- 
monstration than  this  see-saw  movement  of  the  uterus 
by  pushing  the  posterior  cul-de-sac  backwards.  Now 
the  tendency  of  this  falling  of  the  oi'gan  by  the  sudden 
removal  of  a  force  thus  impinging  against  the  point  «, 
is  to  depress  the  fundus  still  more,  which  thereby  pro- 
portionally elevates  the  cervix;  this  draws  up  also  tho 


348  UTERINE    SURGERY. 

cul-de-sac  of  tbe  vagina,  and  rolls  out,  as  it  were,  what- 
ever has  been  deposited  in  it.  In  this  particular  case, 
the  vagina  would  spring  back  from  h  to  a^  and  this  of 
itself  would  eject  the  fluid.  Besides,  in  all  cases  when 
we  examine  the  condition  of  the  uterus  immediately 
after  coition  we  shall  find  the  organ  presenting  signs  of 
exhaustion,  if  I  may  be  allowed  such  an  expression  ;  for 
instance,  if  the  uterus  is  in  a  normal  position,  or  even 
moderately  ante  verted,  we  shall  find  the  upper  part  of 
the  vagina  relaxed,  and  passively  holding  a  large  quan- 
tity of  semen,  in  which  the  cei'vix  uteri  is  submerged ; 
the  uterus  itself  seems  to  be  fatigued,  and  drops  by  its 
own  gravity  down  towards  the  rectum,  where  it  lazily 
sinks  to  the  bottom  of  the  little  pool  of  semen. 

Nothing  has  surjDrised  me  more  than  the  difference 
in  the  relative  condition  of  the  uterus  and  vagina 
before  and  after  sexual  congress.  I  have  had  occasion 
to  examine  many  cases  under  these  circumstances,  and 
I  have  uniformly  found  this  as  I  have  here  described 
it ;  and  when  there  is  reti'oversion  the  fundus  sinks 
still  lower  after  coition  than  before,  and  this  neces- 
sarily elevates  the  os  tincse  still  farther  from  the  semi- 
nal fluid,  if  any  of  it  have  been  retained.  I  have  seen 
many  cases  of  retroversion  latterly  where  the  semen 
was  not  retained.  I  could  give  some  most  interesting 
details  on  this  point,  but  enough  has  been  said  to  show 
the  importance  of  the  subject,  to  illustrate  its  philoso- 
phy, and  to  indicate  the  proper  treatment ;  which,  of 
course,  would  be  to  place  the  uterus  in  its  normal 
position,  and  to  retain  it  there  by  means  of  a  proper- 
ly-fitted instrument  to  be  worn  during  sexual  congress. 
In  the  case  figured  above,  amputation  of  the  cervix  at 
the  point  indicated  by  the  dotted  line  would  be  advis- 
able before  attempting  further  treatment. 


SECTION   VII. 


FOR  CONCEPTION,  SEMEN  WITH  LIVING  SPERMA- 
TOZOA  SHOULD   BE    DEPOSITED   IN   THE 
VAGINA  AT  THE  PROPER  TIME. 


SECTION  VII. 

FOR   CONCEPTION,    SEMEN    WITH   LIVING   SPERMATOZOA 

SHOULD    BE   DEPOSITED    IN  THE    VAGINA    AT   THE 

PROPER   TIME. 

This    proposition   naturally   involves   three    considera- 
tions: 

1st.  The  nature  and  properties  of  semen. 

2nd.  Its  passage  to  the  cavity  of  the  uterus  ;  and 

3rd.  The  proper  time  for  this. 

The  seminal  fluid,  as  ejected  in  the  act  of  copula- 
tion, is  composed  of  the  secretion  of  the  testes,  mixed 
with  that  of  the  vesiculse  serainales,  prostate  and  Cow- 
per's  glands. 

The  office  of  the  testes  is  to  secrete  the  semen,  which 
is  composed  of  the  liquor  seminis,  granules,  and  sper- 
matozoa. 

If  we  take  a  drop  of  semen  from  the  vagina  imme- 
diately after  sexual  intercourse,  and  place  it  under  the 
microscope,  we  shall  see  the  hurried  movements  of 
seemingly  thousands  of  spermatozoa.  But  this  is  not 
the  best  way  of  studying  the  phenomena  of  their  move- 
ments. The  best  plan  is  to  take  a  drop  of  mucus  from  the 
canal  of  a  perfectly  normal  cervix  uteri  some  fifteen  or 
twenty  hours  after  sexual  intercourse.  We  shall  then 
be  better  able  to  examine  the  spermatozoa ;  for  we  shall 
see  them  in  the  fluid  that  serves  as  the  means  of  their 
finding  their  way  towards  the  ovum.  "We  shall  find 
them  moving  more  slowly,  more  cautiously,  if  the  term 
may  be  allowed.     Suppose  we  select  any  one  sperma- 


352  UTERINE    SURGERY. 

tozoon  far  observation,  and  note  particularly  its  various 
actions  and  movements.  It  will  swim  first  one  way  and 
then  another,  or  move  in  a  straight  line  across  the  field 
of  vision ;  and  pei'haps  turn  abruptly  to  retrace  the 
path  already  traversed.  It  it  encounters  a  large  epithe- 
lial scale  it  stops,  places  its  head  against  it,  as  though 
trying  to  push  it  forwards ;  and  when  it  fails  so  to  do, 
it  turns  and  moves  off  slowly  in  another  direction, 
perhaps  to  encounter  another  opposing  obstacle,  to 
pause  a  moment  and  make  another  effort  to  overcome 
it,  and  then  to  turn  again  in  search  of  some  new  field 
of  exploration. 

Fig.  136,  a^  represents  the  appearance  of  sperma- 
tozoa in  a  normal  state.  With  the  spermatozoon  motion 
is  life,  and  as  long  as  it  lives  it  moves.  When  the  tail 
ceases  its  movements,  the  organism  is  dead.  The  alter- 
nate lateral  movements  of  the  caudal  portion  drive  the 


\ 


y 


Fia.  136.  Pio.  137. 

head  forwards.  If  by  any  accident  this  be  injured,  thea 
the  movements  of  the  body  or  head  are  in  accordance 
with  the  nature  of  the  power  exerted  by  the  injured 
part. 

For  instance,  if  the  extreme  point  of  the  tail  should 
be  curled  up,  either  by  an  injury  or  be  held  so  by 


SPERMATOZOA.  353 

inspissated  mucus,  as  is  represented  in  fig.  136,  J,  tlieu 
tlie  movements  of  the  spermatozoon  will  be  in  a  straight 
line,  as  shown  by  the  arrow.  If  the  injury  be  such  as 
to  give  a  permanent  gentle  curvature  to  the  middle  of 
the  tail,  as  shown  in  fig.  137,  then  its  movements  will 
be  in  a  circle,  because  the  extremity  drawing  constantly 
against  the  resisting  fluid  always  in  one  direction,  will, 
of  course,  drive  the  head  always  in  a  corresponding 
direction.  For  instance,  if  the  tail  be  permanently 
turned  to  the  left,  as  here  represented,  then,  with  every 
contraction  of  it,  the  head  will  be  driven  round  to  the 
left;  and  if  to  the  right  (fig.  138),  then  it  will  turn  in 
a  circle  to  the  right.  But  when  we  find  a  spermatozoon 
injured  so  as  to  be  doubled  on  itself  in  the  middle,  with 


Fig.  138.  Fio.  1?9, 

the  tail  reaching  up  by  or  beyond  the  head,  as  shown 
in  fig.  139,  then  its  movements  will  be  in  the  opposite 
direction  to  the  curvature,  because  the  moving  power 
will  be  expended  at  the  very  end  of  the  caudal  portion, 
and  this  force  necessarily  drives  the  head  in  an  opposite 
direction. 

Spermatozoa  cease  to  move  only  when  life  is  extinct. 
Under  favourable  circumstances,  they  live  many  hours  ; 
but  under  unfavourable  circumstances  they  die  quickly. 
For  instance,  any  great  variation  in  temperature  is  fatal 
to  their  existence. 

23 


54  UTERINE    SURGERF. 

For  impregnation,  the  semen  must  contain  living 
spermatozoa.  It  has  been  pretended  by  some  that  it 
may  take  place  without  them.  They  are  to  be  found 
in  all  animated  nature.  I  should  as  soon  think  of  con- 
ception without  the  presence  of  semen,  as  to  suppose  it 
possible  without  spei-matozoa. 

A  short  time  ago  it  was  generally  supposed  that 
sterility  was  a  thing  that  belonged  almost  wholly  to  the 
opposite  sex.  Mr.  Cui'ling*  has  recently  brought  this 
subject  prominently  before  the  profession,  and  has 
established  very  conclusively  that  sterility  in  the  male 
does  positively  exist,  and  that  it  may  depend  upon — 

1st.  Congenital  malposition  of  the  testes. 

2nd.  Chronic  inflammation  of  these  glands  ;  and 

8rd.  Stricture. 

In  the  first  and  second,  the  testes  fail  to  produce 
spermatozoa;  in  the  third,  the  semen  regurgitates  into 
the  bladder. 

When  the  testes  are  retained  in  the  abdomen,  they 
seem  to  remain  in  a  rudimentary  state,  and  never  attain 
the  power  of  secrethig  semen  with  spermatozoa. 

Mr.  Curling's  admiraV>le  paper  contains  a  number 
of  cases  illustrating  this  fact,  and  he  arrives  at  the  very 
just  conclusion  that  the  semen  of  such  testes  being 
devoid  of  the  fructifying  principle,  is  wholly  incapable 
of  procreation.  Mr.  Curling  says  that  Mr.  Poland  and 
Mr.  Cock  have  each  seen  cases  of  procreation  where 
the  testes  never  descended  into  the  scrotum;  but  in 
neither  of  these  cases  had  the  semen  been  examined 
microscopically.      The   inference   in    both   instances   is 


*  "  Observations  on  Sterility  in  Man,"  with  cases.  By  T.  B.  Curling, 
F.R.S.,  Surp:eon  to  the  Lrondop  Hospital,  &c.  Keprinted  from  the 
British  and  Foreign  Medico-  Chirvf  jical  Review.     April,  1864. 


SPERMATOZOA.  355 

plain:  either  that  there  are  exceptions  to  tho  lule  that 
a  retained  testis  does  not  furnish  spermatozoa ;  or  that 
the  claims  to  paternity  in  their  cases  were  entirely  out 
of  the  question.  The  latter  the  most  probable,  as  there 
are  no  f^cts  to  substantiate  the  former. 

In  the  French  school  this  subject  hss  been  very 
thoroughly  investigated.  The  writings  of  Goubaux,  of 
Follin,  of  Gosselin,  and  Godard,  all  go  to  pi'ove  that  a 
retained  testicle  is,  as  a  rule,  whether  in  man  or  animal, 
incapable  of  producing  spermatozoa,  and  that  semen 
without  spermatozoa  is  incapable  of  procreation.  In 
some  instances,  one  testis  has  been  found  in  the  abdo- 
men, and  the  other  in  its  normal  position  in  the 
scrotum ;  and  here,  the  one  has  invariably  been  defi- 
cient, and  the  other  prolific  in  spermatozoa. 

But  while  the  presence  of  spermatozoa  is  essential 
to  fecundation,  their  absence  has  no  sort  of  influence 
upon  impotence.  By  impotence,  we  understand  an 
incapacity  for  copulation ;  by  sterility,  an  incapacity 
for  fructification.  Thus  a  man  may  be  impotent  and 
not  sterile ;  and  sterile  but  not  impotent.  I  have 
known  many  men  who  performed  the  act  of  coition 
with  the  greatest  vigour,  whose  semen  was  perfectly 
devoid  of  the  slightest  trace  of  spermatozoa;  and  on. 
the  other  hand,  how  often  do  we  encounter  those  who 
are  incapable  of  the  least  efi^ort  at  copulation,  but  whose 
semen  is  loaded  with  spermatozoa.  In  the  first  class, 
ignorance  of  their  real  condition  is  bliss ;  while  in  the 
second,  the  certain  knowledge  of  their  infirmity  pro- 
duces the  greatest  misery. 

The  seminal  fluid  may  be  destitute  of  spermatozoa 
in  consequence  of  an  obstruction  of  the  excretory  duct6 
of  the  testes.  This  is  the  result  usually  of  acute  inflam- 
mation of  these  organs.     Gonorrhoea  has  been  regarded 


356 


UTERINE    SURGERY. 


as  a  disease  of  uo  very  serious  importance ;  but  when 
we  see  it  often  producing  a  double  orchitis,  which  may 
leave  the  subject  of  it  sterile  for  ever  afterwards,  we 
should  look  upon  it  rather  as  an  affection  likely  to  be 
attended  with  the  most  disastrous  consequences. 

I  now  call  to  mind  three  young  men  whom  I  treated 
for  double  orchitis,  following  gonorrhoeal  inflammation, 
about  twenty-five  years  ago,  which  left  in  each  a 
chronic  double  epididymitis.  They  l^ave  been  married 
many  years  without  issue.  It  is  true  their  wives  may 
have  been  sterile.  On  this  point  I  cannot  do  better 
than  to  quote  from  Mr.  Curling,*  w^ho  says : — 

"In  1853,  M.  Gosselin  made  known  some  curious 
researches  in  relation  to  this  subject.  He  carefully  ex- 
amined the  semen  in  twenty  men  who  had  been  attacked 
with  double  epididymitis  after  gonorrhoea.  In  fifteen 
of  these  cases  which  were  comparatively  recent,  a  callo- 
sity existed  in  the  tail  of  the  epididymis  at  the  time 
they  seemed  to  be  cured.  In  all,  the  genital  functions 
appeared  fully  restored  and  the  sperm  normal.  The 
semen  was  repeatedly  examined  at  intervals  of  several 
weeks,  but  no  spermatozoa  were  detected.  M.  Gosselin 
lost  sight  of  all  but  two  cases,  and  in  these  the  return 
of  spermatozoa  in  the  semen  occuri-ed  after  some 
mouths,  and  coincidently  with  the  complete  disappear- 
ance of  the  induration  in  the  epididymis  on  one  side. 
In  the  remaining  five  of  the  twenty  cases  the  double 
epididymitis  had  occurred  several  years  previously. 
One  man,  aged  forty-five,  had  been  attacked  twenty 
years  before,  but  the  left  callosity  no  longer  existed, 
and  spermatozoa  were  found  in  the  semen.  In  another 
man  the  disease  dated  back .  five  years,  and  had  left  a 

♦  Loe.  cU. 


SPERMATOZOA.  35(7 

considerable  induration  at  the  lower  part  of  each  epidi- 
dymis. The  general  health  was  good.  No  spermatozoa 
could  be  detected.  In  the  three  other  cases  the  disease 
had  occurred  ten,  six,  and  four  years  before.  There  waa 
hardness  on  both  sides.  The  testicles  were  otherwise 
unaltered.  The  indications  of  virility  were  quite  satis- 
ftictory,  and  the  semen  presented  its  usual  appearance. 
The  individuals  had  all  been  married  several  years,  but 
had  no  children.  The  sperm  was  carefully  examined 
and  found  destitute  of  spermatozoa.  One  of  them  had 
had  children  by  a  former  wife  before  the  attack  of 
double  epididymitis.  Since  the  publication  of  the  pre- 
cedins"  observations,  M.  Gosselin  has  met  with  two 
cases  of  men  who,  after  suffering  from  bilateral  ej^ididy- 
mitis  during  their  youth,  had  retained  an  induration  on 
each  side.  They  had  been  married  several  years  and 
had  no  children.  In  both  the  virile  powers  were  not, 
apparently,  weak,  but  the  sperm  was  entirely  wanting 
in  spermatozoa. 

Thus  it  will  be  seen  that  inflammation  of  the  testes 
is  a  mattei'  of  grave  importance.  And  this  is  so  whether 
it  be  the  result  of  specific  causes,  of  accident,  of  cold,  or 
of  translated  parotitis.  I  have  known  one  case  of  epidi- 
dymitis from  mumps,  where  the  testes  lost  the  power  of 
generating  spermatozoa.  It  is  a  curious  and  fortunate 
circumstance  that  epididymitis,  by  whatever  cause  pro- 
duced, in  no  way  weakens  the  sexual  appetite,  or  the 
power  of  gratifying  it. 

Semen  destitute  of  spermatozoa  has  the  usual  sui 
generis  odour,  but  lacks  the  appearance  of  uniformity 
that  belongs  to  the  normS^  secretion.  When  viewed  by 
a  transmitted  light,  we  usually  see  little  whitish  flakes 
of  mucus  floatini>:  throuo-h  it.  But  I  have  seen  two 
instances  in  which  it  had  the  colour  and  appearance 


358  UTERINE  SURGERY. 

of  good  semen,  although  wantuig  spermatozoa  It  ig 
insoluble  in  hot  or  cold  water,  and  floats  about  in  it 
immiscibly  in  cloudy  flakes  like  ordinary  mucus.  It 
is  more  translucent  than  good  semen,  less  milky,  and 
less  opaque.  Under  the  microscope  it  presents  the 
appearance  of  ordinary  mucus.  I  have  seen  samples 
of  semen  full  of  spermatozoa,  but  loaded  with  mucus, 
which  pi'obably  came  from  the  glandular  apparatus 
at  the  neck  of  the  bladder.  I  know  of  one  case 
illustrating  the  fact  that  a  man  is  not  necessarily 
sterile  because  his  semen  possesses  too  large  a  proportion 
of  mucosity. 

Normal  semen  will  drop  from  the  end  of  the  syringe 
in  drops  as  easily  as  water.  A  small  quantity  falling 
into  a  glass  of  water  is,  by  slight  agitation,  imme- 
diately diffused  or  dissolved  in  it.  Abnormal  semen 
full  of  mucus  will  not  leave  the  mouth  of  the  syringe 
quickly  or  suddenly,  but  ropes  oif  for  an  inch  or  more 
before  it  breaks  into  a  drop ;  and  when  it  falls  into 
water  it  preserves  its  tenacity,  and  but  a  small  part  of 
it  is  dissolved.  It  floats  about  in  shreds,  and  eventually 
settles  at  the  bottom  of  the  glass  in  the  form  of  a 
whitish  sediment. 

Sometimes  sterility  in  the  male  depends  upon  a 
stricture  obstructing  the  outward  passage  of  the  semen, 
which  consequently  in  the  act  of  copulation  regurgitates 
into  the  l)ladder.  This  condition  of  thinsrs  is,  of  course, 
curable  by  the  proper  treatment  for  stricture. 

At  the  beginning  of  this  section  I  said  that,  to  ensure 
conception,  "  semen  with  living  spermatozoa  should  be 
deposited  in  the  vagina  at  the  proper  time." 

It  is  the  vulgar  opinion,  and  the  opinion  of  many 
savants,  that,  to  ensure  conception,  sexual  intercourse 
should  be  performed  with  a  certain  degree  of  complete- 


SEXUAL  CONGRESS.  359 

ness,  that  would  give  an  exhaustive  satisfaction  to  both 
parties  at  tlie  same  moment.  Even  RoubaucP  has 
devoted  many  pages  to  the  consideration  of  frigidity  in 
the  woman.  How  often  do  we  hear  husbands  comphxiu 
of  coldness  on  the  part  of  wives  ;  and  attribute  to  this 
the  failure  to  proci"eate.  And  sometimes  wives  are  dis- 
posed to  think,  though  they  never  complain,  that  the 
fault  lies  with  the  hasty  ejaculation  of  the  husband. 
Both  are  wrono;. 

God  has  given  us  appetites*  and  desires,  and  endowed 
the  act  of  copulation  with  a  pleasurable  erethism, 
simply  that  we  might  be  forced  to  "  multiply  and 
replenish."  But  for  this,  the  human  ftimily  might,  long 
ago,  have  been  numbered  with  the  fossils  that  repre- 
sent extinct  species.  No ;  it  matters  not  how  awk- 
wardly and  unsatisfactorily  the  act  of  coition  may  be 
j^erformed,  so  that  semen  with  the  proper  fructifying 
principle  be  placed  in  the  vagina  at  the  right 
moment;  and,  on  the  contrary,  it  matters  not  how 
perfectly  and  satisfactorily  it  may  be  done,  if  the  semen 
lacks  this  fecundating  power.  I  have  known  many 
men  who  knew  but  little  of  mere  animal  sensuality, 
and  whose  wives  knew  less,  and  yet  they  were  blessed 
v/ith  large  families  ;  and,  on  the  contrary,  I  have  known 
some  who  were  differently  constituted,  and  yet  they 
were  perfectly  sterile. 

It  might  be  thought  that  I  am  here  overstepping  the 
bounds  of  propriety,  even  in  a  work  purely  surgical ; 
but  I  justify  myself  by  the  fact,  that  a  false  philosophy 
has  gained  almost  universal  credence ;  and  that  young 
medical  men,    with    a    correct    knowledge  of   facts  as 


♦  "  Traite  de  I'lmpuissance  et  de  la  Stcrilite  chez  rHomme  et  chez  la 
Femme."     Par  le  Dr.  Felix  Roubaud.     Paris  :  J.  B.  Bailliera     1865. 


3(30  UrERINE  SURGERY. 

they  truly  exist,  may  do  mucli  to  render  many  families 
happier,  by  setting  them  right  on  a  point  of  more  vital 
importance  to  domestic  happiness  than  many  of  us  have 
ever  dreamed  of. 

Let  us  turn  to  pages  331  and  332,  and  read  over 
the  cases  in  which  conception  took  place  while  the 
wives  were  etherized,  and  ask  ourselves  what  agency 
mere  sensual  enjoyment  could  have  had  in  bringing 
about  the  result.  Our  literature  furnishes  many  cases 
where  the  seminal  fluid  has  been  lost  at  the  mouth  of 
the  vagina;  where  the  hymen  has  remained  intact; 
and  where,  nevertheless,  conception  readily  occurred. 

I  have  seen  cases  of  this  sort ;  so  has  Sir  Joseph 
Olliffe;  and  so  has  Dr.  Campbell,  of  Paris.  Most  of 
these  were  cases  of  vaginismus,  where  the  pain 
and  spasm  of  the  sphincter  vaginae  were  such  as  to 
preclude  penetration,  and  the  semen  was  lost  at  the 
ostium  vaginae,  a  little  passing  through  the  hymen. 

M.  Tardieu,*  Dean  of  the  Faculty  of  Paris,  relates 
a  remarkable  instance  of  conception  following  lascivious 
titillations  under  most  unnatural  and  unfortunate  circum- 
stances. Here  the  semen  was  habitually  lost  at  the 
ostium  vaginae,  with  the  belief  that  conception  could 
not  occur  unless  the  act  of  coition  was  fully  consum- 
mated. But  the  sequence  proved  otherwise  ;  and  M. 
Legrand,  who  delivered  her,  found  the  young  girl's 
vagina  virginal. 

I  once  requested  the  husband  of  a  lady  who  had 
vaginismus,  to  let  me  see  his  wife  an  hour  after  sexual 
intercourse,  for  the  purpose  of  determining  whether  any 
semen  ever  entered  the  vagina.     He  had  not  attempted 


*  "  E  ude  Medico-legale  sur  les  Attentats  aux  Moeurs."     Par  Ambroise 
Tardieu,  Professeur,  &c.     Paris :  J.  B.  Bailliere  et  Fiis,  1859,  page  99. 


SPERMATOZOA.  ^Q\ 

it  for  ten  days  or  more,  and  he  said  he  was  so  nervous 
at  the  idea  that  he  lost  the  semen  at  the  moment  of 
contact,  and  hence  the  effort  amounted  to  nothing. 

In  consequence  of  this  accident,  I  did  not  see  the 
patient  at  the  appointed  time  ;  but  visited  her  a  few 
hours  hxter  for  some  other  purpose,  and  removed  about 
ten  drops  of  clear  translucent  mucus  from  the  canal  of 
the  cervix.  The  attempt  at  copulation  was  made  at 
eight  a.m.,  the  patient  did  not  rise  from  bed  till  eleven. 
At  twelve  I  saw  her,  and  then  removed  the  cervical 
mucus.  I  intended  to  make  a  microscopic  examination 
of  it  at  once,  but  circumstances  put  it  out  of  my 
power,  and  I  did  not  do  this  till  midnight,  being  twelve 
hours  after  its  removal,  and  sixteen  hours  after  the 
attempt  at  intercourse. 

In  this  cervical  mucus  I  found  a  solitary  spermato- 
zoon, which  manifested  the  greatest  activity.  I  exa- 
mined the  whole  of  the  ten  drops  of  mucus,  but  could  not 
discover  another  one,  nor  was  there  any  in  the  vaginal 
mucus.  How  did  only  one  spermatozoon  and  no  more 
find  its  way  into  the  canal  of  the  cervix  ?  Perhaps  not 
more  than  a  drop,  or  half  a  drop,  of  semen  passed 
through  the  little  hymeneal  opening.  The  patient  lay 
in  bed  three  hours  afterwards.  During  this  time  this 
stray  spermatozoon  had  travelled  three  inches  and  a 
half  from  the  hymen  to  the  os  tincoe  (for  the  vagina  was 
very  long  and  narrow),  and  had  entered  into  the  canal 
of  the  cervix,  while  the  remainder  of  the  seminal  fluid 
passed  off  in  resuming  the  erect  posture.  The  case  is 
curious,  as  showing — 

1st.  That  semen  can  be  thrown  into  the  vagina  with' 
out  penetration. 

2nd.  That  a  spermatozoon  can,  in  a  comparatively 
short  time,  move  over  a  considerable  distance  ;  and 


362  UTERINE  SURGERY. 

3rd.  That  it  can  live  a  long  time  out  of  the  body, 
provided  the  temperature  is  not  too  low.  This  observa* 
tion  was  made  on  one  of  the  hottest  days  in  July. 

We  know  very  well  that  the  semep,  or  rather  it; 
fructifying  pi-inciple,  the  spermatozoa,  must  pass  into  the 
cavity  of  the  uterus,  if  not  further,  to  render  conception 
possible.  How  is  this  done  ?  Does  it  enter  the  canal 
of  the  cervix  in  the  act  of  ejaculation?  or  do  the  sper- 
matozoa afterwards,  by  their  locomotive  powers,  gradu- 
ally wend  their  way  up  the  canal  of  the  cervix? 

I  am  not  aware  that  any  observations  on  the  living 
subject  have  before  been  made  upon  this  point.  A  few 
post-mortem  examinations,  made  in  cases  of  sudden  death 
after  coition,  have  demonstrated  the  presen(;e  of  sperma- 
tozoa in  the  cavity  of  the  uterus  ;  but  this  does  not  settle 
the  questions  raised  above.  The  fact  that  pregnancy 
has  frequently  occurred  without  penetration,  proves  very 
^conclusively  that  the  spermatozoa  can  and  do  traverse 
the  whole  length  of  the  vagina ;  that  they  then  can  and 
do  enter  the  canal  of  the  cervix,  and  passing  along  this 
narrow  strait,  that  they  can  and  do  pass  on  till  they 
reach  the  ovum,  and  fertilize  it.  But  this  is  not  the 
usual  way  in  which  this  is  done. 

T  have  over  and  over  again  examined  the  condition 
of  the  uterus  after  coition,  and  often  in  four  or  five 
minutes  after  it ;  and  I  have  usually  found  the  state  of 
things  described  on  page  348.  I  have  also  frequently 
removed  the  mucus  of  the  cervical  canal  immediately 
after  sexual  intercourse,  first  a  drop  from  the  os  tincse, 
and  then  a  drop  or  two  from  an  inch  higher.  If  the 
neck  of  the  womb  is  in  a  normal  condition,  with  an  open 
OS  tincse  filled  with  healthy  mucus,  we  shall  always  find 
spermatozoa  in  it,  in  greater  or  less  numbers,  if  we  exa- 
mine it  immediately  after  coition. 


SPERMATOZOA.  3Q3 

Thus  we  see  that  they  euten'  the  cervix,  as  it  were^ 
suddenly.  My  explanation  of  tliis  physiological  pheno- 
menon is,  that  the  cervix  is  pi-essed  forcibly  against  the 
glans  by  a  contraction  of  the  superior  constrictor  vagi- 
uie ;  that  .this  pressure  necessarily  forces  out  the  contents 
of  the  canal  of  the  cervix ;  that  the  parts  subsequently 
become  relaxed,  the  uterus  returns  suddenly  to  its  normal 
condition,  and  the  seminal  fluid  filling  the  vagina,  neces- 
sarily rushes  into  the  canal  of  the  cervix  by  a  process 
similar  to  that  by  which  a  fluid  would  pass  into  an  India- 
rubber  bottle  slightly  compressed,  so  as  to  expel  a  por- 
tion of  its  contents  before  placing  its  mouth  in  a  fluid 
of  any  sort. 

If  the  uterus  is  in  a  normal  condition,  we  shall 
always,  as  a  rule,  find  spermatozoa  in  the  canal  of  the 
cervix  immediately  after  coition.  If  the  uterus  is  greatly 
retroverted,  we  shall  not ;  and  if  it  is  greatly  anteverted 
we  shall  not.  And  why  ?  Because,  in  the  first  instance, 
the  OS  tincge  will  be  too  close  to  the  symphysis  pubis,  and 
if  it  is  subjected  to  any  such  pressure  as  that  alluded  to 
above,  it  will,  for  anatomical  reasons,  be  such  as  to  com- 
press the  posterior  lip  of  the  os  tincse  up  against  the 
anterior,  which  will  have  no  eftect  in  exhausting  the 
canal  of  the  cervix ;  and  in  the  second  instance,  whei-e 
there  is  a  complete  antevei'sion,  with  the  os  looking  in 
the  direction  of  the  hollow  of  the  sacrum,  the  same  act 
and  the  same  pressure  would  only  force  the  anterior  lip 
of  the  OS  tincse  up  against  the  posterior,  creating  no 
vacuum,  and  making  no  room  for  the  newly  introduced 
fluid. 

From  this  it  will  be  seen  that  I  believe  the  cervix 
uteri  to  be  shortened  in  the  erethismal  climax  of  coition, 
by  pressure  exerted  upon  it  in  the  direction  of  its  long 
axis  when  its  position  is  normal,  which  is  impossible  in 


364  UTERIXE    SURGERY. 

any  greatly  abnormal  position.  I  have  spoken  of  a 
superior  consti-ictor  vaginae,  and  attributed  to  it  a  cer- 
tain office — that  of  compressing  the  glans  forcibly  against 
the  OS  tincse  at  a  certain  moment.  I  have  made  no  dis- 
sections to  prove  the  existence  of  such  a  special  muscle  ; 
but  that  it  does  exist,  and  that  some  anatomist  will  dis- 
sect and  describe  it,  I  feel  perfectly  confident,  for  I  have 
seen  the  manifestations  of  its  presence  hundreds  of 
times.  In  uterine  examinations  with  the  patient  on  the 
left  side  and  my  speculum  introduced,  we  may  now  and 
then  see  the  posterior  wall  of  the  vagina  just  opposite 
the  OS  tincse  gradually  contracted  and  corrugated,  till  it 
is  brought  almost  in  contact  with  the  cervix,  evidently 
by  circular  i^ands  of  muscular  fibres  that  occupy  the 
superior  portion  of  the  vagina. 

We  are  more  apt  to  see  this  in  patients  that  are 
alarmed,  and  manifest  some  degree  of  general  nervous 
agitation.  I  have  witnessed  this  over  and  over  again, 
and  what  one  man  sees  another  will  be  sure  to  discover 
when  his  attention  is  turned  in  the  proper  direction. 
It  matters  not  whether  this  explanation  is  correct  or 
not,  provided  other  observers  establish  the  fact  that 
the  semen  finds  its  way  at  once  into  the  canal  of  the 
cervix. 

We  have  already  discussed  many  of  the  mechanical 
obstructions  that  prevent  the  passage  of  the  semen  to 
the  cavity  of  the  uterus ;  and  we  have  seen  that  the 
great  difficulty  is  to  be  found  almost  uniformly  in  the 
cervix. 

It  has,  hence,  occurred  to  many  philosophic  minds, 
to  overleap  this  barrier  at  once,  by  throwing  the  fructi- 
fying agent  right  into  the  cavity  of  the  uterus.  But 
the  practical  execution  of  this  is  surrounded  by  many 
difficulties.      For   instance,  how   delicate  and   difficult 


SPERMATOZOA.  3^,5 

would  it  be  to  arrange  everytliiug  preparatory  to  such 
a  procedure.  Then,  as  to  the  temperature  of  instru 
ments ;  for  the  slightest  variations  of  this,  whether  of 
heat  or  cold,  are  inimical  to  the  life  of  the  spermatozoa. 
Tlien  as^  to  the  quantity  of  semen  to  be  introduced, 
whether  much  or  little ;  the  delicacy  of  the  apparatus 
for  this,  and  the  proper  time  for  the  operation.  When 
all  these  circumstances  are  taken  into  consideration,  we 
can  appreciate  the  difficulties  of  the  practical  execution 
of  a  thing  that  would  at  first  appear  to  be  theoreti- 
cally so  simple  Ever  since  the  days  of  Spallanzani 
and  Rossi,  who,  with  a  syringe,  injected  the  semen  of 
the  dog  into  the  vagina  of  the  bitch,  and  saw  imjjreg- 
nation  follow,  it  has  been  supposed  by  many  that  in  the 
human  subject  this  mechanical  process  might  be  carried 
still  further,  by  injecting  the  semen  into  the  cavity  of 
the  uterus  from  the  canal  of  the  vas^ina.  But  I  know 
of  no  published  account  of  any  experiments  of  this 
sort. 

Some  years  ago,  I  made  a  series  of  this  kind,  and 
actually  saw  conception  follow  this  process  in  one 
instance.  Dr.  George  Harley,  Professor,  <fec.,  in  Uni- 
versity College,  London,  informs  me  that  he  has 
repeatedly  performed  the  experiment  of  injecting  the 
semen  into  the  cavity  of  the  uterus,  but  with  no  result. 
I  have  given  up  the  practice  altogether,  and  do  not 
expect  to  return  to  it  again ;  but  as  others  may  feel 
disposed  to  try  further  experiments  in  this  direction,  I 
shall  here  give  them  the  advantage  of  my  experience. 

Before  undertaking  this  we  must  satisfy  ourselves 
that  the  semen  is  perfectly  normal,  and  that  it  does 
not  and  cannot  enter  the  canal  of  the  cervix  in  the 
natural  way. 

In  all  my  cases  there  was  a  contraction  of  the  canal 


366  UTERINE  SURGERY. 

of  the  cervix,  and  in  two  there  was  quite  a  flexure  at 
the  OS  internum  ;  and  experimental  observations  proved 
that  the  semen  never  entered  the  canal  of  the  cervix 
in  any  one  of  them.  In  all  of  them  the  operation  of 
incising  the  os  and  cervix  would  have  been  the  proper 
course  to  pursue ;  but  my  patients  were  too  timid,  would 
not  submit  to  it,  and  accepted  the  uncertain  alternative 
of  uterine  injection.  In  my  first  experiments  this  was 
often  more  painful  than  any  operation,  for  it  frequently 
produced  severe  uterine  colic.  I  bad  no  data  to  guide 
me,  and  I  began  by  slowly  injecting  three  or  four  drops 
of  the  seminal  fluid,  which  produced  very  severe 
symptoms;  then  two  drops,  and  then  one,  till  finally 
I  determined  that  half  a  drop  was  quite  enough. 
Indeed,  I  have  no  idea  that  this  quantity  ever  gets  into 
the  cavity  of  the  uterus  in  Nature's  own  way,  and  I 
now  wonder  why  I  should  have  begun  these  experi- 
ments in  such  a  heroic  manner.  Suffice  it  to  say  that 
I  have  seen  conception  follow  this  artificial  fructification 
once,  and  once  only.  The  case  is  of  sufficient  import- 
ance to  give  it  in  detail. 

My  patient  was  twenty-eight  years  old ;  had  been 
married  nine  years  without  issue ;  and  had  had  more  or 
less  dysmenorrhoea  all  her  menstrual  life.  It  was  often 
attended  with  great  constitutional  disturbance,  such  as 
nausea,  vomiting,  and  sick  headache.  She  had  retro- 
version, with  hypertrophy  of  the  posterior  wall,  an 
indurated  conical  cei'vix,  a  contracted  canal,  which  was 
particularly  contracted  at  the  os  internum,  in  conse- 
quence of  the  flexure  incidental  to  the  malposition ; 
and  superadded  to  all  these  mechanical  obstructions, 
the  vagina  never  retained  the  semen.  I  examined 
this  case  several  times  very  soon  after  sexual  inter- 
course,  and   I   never    found  a  drop    of  semen    in  the 


SPEEMATOZOA. 


367 


vagina,  althongli  it  was   placed   there   in  the  greatest 
abundance. 

This  patient  was  willing  to  submit  to  anything  but  a 
surgical  operation.  Could  any  case 
have  presented  a  greater  number  of 
difficulties  to  be  overcome  ?  The 
first  thing  to  be  done  was,  of 
course,  to  rectify  the  malposition, 
and  to  keep  the  uterus  in  its 
normal  relations  by  means  of  a 
properly  adjusted  pessaiy,  with  the 
hope  that  the  vagina  would  re- 
tain the  semen.  This  point  has 
been  so  fully  discussed  in  Section 
v.,  that  it  is  mmecessary  to  say 
more  here  than  that  I  fortunately 
succeeded  in  doing  this,  and  a 
sufficient  quantity  of  semen  was 
retained,  though  the  most  of  it 
passed  off.  This  part  satisfactorily 
arranged,  we  were  now  ready  for 
the  uterine  injections.  These  ex- 
tended over  a  period  of  nearly 
twelve  months.  Some  of  them 
(two)  were  made  just  before  men- 
struation ;  the  others  (eight)  were 
made  at  different  periods,  vary- 
ing from  two  to  seven  days  af- 
ter it  ceased.  Beginning  with 
three  drops,  I  at  last  injected  half 
a  drop. 

Fig.  140  represents  the  instrument  with  which  these 
(.'xperiments  were  conducted,  with  the  exception  of  the 
bulb  at  the  end  of  the  tube.     It  is  made  of  erlass.     T.ie 


Fi?.  140. 


3G8 


UTERINE   SURGERY. 


piston  can  be  drawn  out  easily  for  the  purpose  of  taking 
up  the  semen  ;  but  for  the  purpose  of  graduating  exactly 
the  quantity  to  be  injected,  there  was  a  little  screw  nut, 
a.  which  could  be  turned  against  the  piston-rod,  upon 
which  a  screw  was  cut.  This  prevented  the  piston  from 
being  forced  down,  except  by  the  action  of  the  screw. 
When  we  wished  to  force  out  the  contents  of  the  syringe, 
half  a  revolution  of  the  piston  forced  out  half  a  drop,  a 
whole  revolution  a  whole  drop,  and  so  on,  just  as 
does  Pravaz's  instrument  for  the  endermic  injection  of 
morphine.  The  greatest  care  was  necessary  in  manag- 
ing the  temperature  of  the  syringe.  I  placed  it  in  a 
bowl  of  warm  water,  with  a  thermometer  to  mark  98° 
Fah.,  taking  care  to  have  it  no  more  and  no  less. 
But  as  the  removal  of  the  instrument 
from  the  bowl  of  water  to  the  vagina 
would  be  necessarily  attended  with  a  dimi- 
nution of  temperature,  I  adopted  the  plan 
of  allowing  it  to  remain  about  a  minute 
in  the  vagina  before  drawing  up  any  of 
the  semen  into  it ;  and  this  for  the  pur- 
pose of  insuring  it  to  be  the  same  tempe- 
rature as  the  fluid  in  which  the  sperma- 
tozoa disported. 

Fig.  141  represents  the  exact  size  of 
the  glass-tube,  used  the  last  time  in  thia 
case ;  a  is  the  point  at  which  a  string 
was  tied,  as  a  guide  and  a  guard  to  pre- 
vent its  being  introduced  too  far  into 
the  cavity  of  the  uterus.  This  was  exactly 
one  inch  and  nine-sixteenths  from  the  end, 
which  I  think  is  quite  as  far  as  we  should 
introduce  the  instrument.  Thus  it  was  not 
carried  so  far  as  to  injure  the  lining  membrane  of  the 


Fig.  141. 


SPERMATOZOA.  3g9 

uterus,  or  to  mar  the  vitality  of  the  ovum,  if  it  had 
ah'eady  reached  this  cavity.  1  feared  that  I  might  have 
done  one  or  both  of  these  in  some  of  my  earlier  experi- 
ments. In  this  particular  case,  about  four  drops  of  semen 
were  taken  up ;  the  instrument  was  cautiously  carried 
into  the  canal  of  the  cervix,  till  the  point  was  in  close 
contact  with  the  os  tincsB;  then  the  piston-rod  was 
slowly  turned  half  a  revolution,  which  as  slowly  forced 
out  half  a  drop  of  semen ;  the  instrument  was  held  in 
situ  for  ten  or  fifteen  seconds  and  then  withdrawn,  and 
the  patient  lay  quietly  in  bed  for  two  or  three  hours 
afterwards. 

Under  these  circumstances,  at  this,  the  tenth  trial, 
conception  took  place,  and  everything  went  on  favour- 
ably till  the  fourth  month,  when  a  fall  and  a  fright 
unfortunately  produced  a  miscarriage,  from  which  the 
mother  recovered  with  the  greatest  difficulty.  I  have 
related  this  case  minutely,  because  I  presume  it  is  the 
first  and  only  authentic  case  in  which  artificial  fertiliza- 
tion has  been  successful  in  the  human  species;  and 
because  it  furnishes  about  the  sum  and  substance  of 
my  knowledge  on  the  subject  which  may  be  of  any 
possible  service  as  a  guide  to  future  observers,  who  may 
have  the  curiosity,  leisure,  courage,  and  perseverance 
to  experiment  further  in  this  direction. 

The  experiments  above  alluded  to  were  made  on 
half  a  dozen  different  patients.  During  the  two  years 
that  I  was  engaged  in  them,  I  made  fifty-five  uterine 
injections.  I  think  I  am  entitled  to  subtract  about  half 
the  number  as  having  been  badly  done,  or  having  been 
made  v.'ith  badly  constructed  instruments,  or  under  inju- 
dicious circumstances.  If  so,  then  they  show  one  concep- 
tion out  of  about  twenty-seven  trials.  I  have  very  little 
doubt  that  we  shall  learn  still  more  about  embryology ; 

24 


370  UTERINE   SURGERY. 

and  some  years  hence,  when  we  shall  better  understand 
the  laws  of  conception,  I  doubt  as  little  that  some  one 
will  be  able  to  apply  the  principles  sought  to  be  esta- 
blished by  these  experiments  with  more  exactitude  than 
I  have.  If  we  understood  more  about  the  proper  period 
for  conception,  this  mechanical  fertilization  might  be- 
come exact  enough  to  depend  upon  it  in  such  cases  as 
would  be  otherwise  impracticable. 

Science,  even  in  our  own  day;  demonstrates  now  and 
then  the  wisdom  of  laws  given  under  the  Mosaic  dis- 
pensation. As  an  instance,  I  have  only  to  refer  to  the 
recent  discovery  of  Trichinae  in  swine,  as  showing  not 
only  its  occasional  unfitness,  but  its  positively  poisonous 
qualities  as  an  article  of  diet  under  some  circumstances. 
Then,  again,  the  laws  bearing  on  the  uncleanness  and 
the  purification  of  women  in  menstruation,  are  in  accord- 
ance with  the  accepted  doctrines  of  the  day,  in  regard 
to  the  period  of  fitness  for  conception.  "  But  if  she 
be  cleansed  of  her  issue,  then  she  shall  number  to 
herself  seven  days,  and  after  that  she  shall  be  clean." 
— Levit.  XV.  28. 

It  is  pretty  well  established  that  menstruation  is  the 
sign  of  ovulation ;  that  it  is  preparatory  to  the  recep- 
tion of  the  ovum ;  that  the  ovum  reaches  the  cavity  of 
the  uterus  in  from  two  to  ten  days  after  menstruation ; 
and  that  it  must  be  fertilized  at  some  point  between  the 
ovary  and  the  os  internum,  by  coming  in  contact  with 
the  spermatozoa.  Dr.  Ritchie*  of  Glasgow  believes,  with 
many  other  modern  Physiologists,  that  the  uterus  itself 
is  the  normal  seat  of  conception. 


*  "  Contributions  to  Assist  the  Study  of  Ovarian  Physiology  and  Patho- 
logy." By  Charles  G.  Ritchie,  M.D.,  &c.,  &c.,  p.  101.  John  Churchill  St 
Sons.    1865. 


SPERMATOZOA.  371 

T^ow,  if  all  this  be  so,  it  follows  that  the  best  time 
to  insure  this  fructification  is  within  the  ten  days  follow- 
ing menstruation.  This  is  the  generally  accepted  doc- 
trine in  regard  to  the  most  fitting  time  for  conception. 
I  have  no  doubt  that  conception  may  take  place  at  any 
period  whatever,  relatively  to  the  return  of  menstrua- 
tion ;  but  there  is  hardly  a  question  that  it  occurs  more 
frequently  within  the  ten  days  following  this  period. 
I  know  of  several  instances  in  which  it  undoubtedly 
occurred  within  the  week  preceding  the  expected  return 
of  the  flow. 

Sir  Joseph  Olliffe  and  I  sent  a  patient  of  ours  to  Spain, 
in  the  spring  of  1864.  She  had  been  under  treatment 
for  menorrhagia  for  three  or  four  months,  and  lived 
entirely  apart  from  her  husband  during  the  whole  of 
this  time.  They  were  ordered  to  live  apart  till  she 
should  pass  over  one  period  in  Spain.  Everything  went 
on  according  to  our  prescription  till  about  forty-eight 
hours  before  the  expected  appearance  of  the  flow,  when 
by  accident,  as  sometimes  happens,  the  injunction  of  the 
doctors  was  momentarily  forgotten,  and  the  period  did 
not  come  at  the  expected  time.  Indeed,  she  conceived, 
and  in  due  time  was  delivered  of  a  daughter. 

The  husband  of  a  lady  of  great  eminence,  aged  thirty, 
the  mother  of  three  sons,  the  youngest  three  years  old, 
was  absent  in  the  Holy  Land  for  five  months,  and  re- 
turned exactly  five  days  before  the  expected  recurrence 
of  his  wife's  menses.  He  spent  but  one  night  at  home, 
being  suddenly  called  off  for  several  days  by  some 
urcent  business.  His  wife  conceived,  and  bore  him  a 
daughter. 

I  had  a  lady,  aged  twenty-eight,  nearly  two  months 
under  treatment  for  some  cervical  disease.  The  case 
was  treated  entirely  with  tampons  of  cotton-wool,  wet 


372  UTERINE    SURGERY. 

with  glycerine,  holding  in  solution  various  remedies, 
such  as  tannin.  When  she  was  thought  to  be  well 
enough  to  return  home,  her  husband  came  for  her.  I 
wished  to  see  if  the  secretions  were  normal.  Sexual 
intercourse  took  place,  at  my  request,  two  days  before 
the  expected  return  of  menstruation.  It  did  not  appear. 
She  had  conceived,  and  in  due  time  a  son  was  born. 

I  can  vouch  for  the  relialjility  of  the  parties  alluded 
to  above.  I  have  related  these  three  cases  to  illustrate 
the  fact,  that  conception  can  and  does  take  place  just 
on  the  eve  of  the  approach  of  menstruation ;  a  thing, 
by  the  bye,  that  is  not  denied.  I  could  give  several 
reliable  cases  where  the  circumstances  were  such  as  to 
prove  that  conception  could  only  have  occurred  within 
a  week  or  ten  days  following  the  cessation  of  the  flow. 

When  I  was  engaged  in  the  philosophic  experiments 
of  artificially  introducing  the  semen  into  the  cavity  of 
the  womb,  I  had  to  make  some  fifteen  or  twenty  essays 
before  I  was  satisfied  of  the  quantity  of  semen  to  be 
introduced,  but  as  to  the  proper  time  for  this  I  never 
felt  entirely  sure.  For  those  who  are  very  anxious  for 
offspring,  I  usually  oi'der  sexual  intercourse  on  the  third, 
fifth,  and  seventh  days  after  the  flow  has  ceased  ;  and  ou 
the  fifth  and  third  before  its  expected  return ;  and  but 
on(;e  on  ench  day.  For  the  most  obvious  reasons  this 
should  alv^ays  be  on  going  to  bed  at  night,  instead  of 
just  before  i-ising  in  the  morning.  The  horizontal  pos- 
ture favours  the  retention  of  the  semen ;  the  erect  its 
expulsion.  I  am  satisfied  that  too  frequent  sexual  in- 
dulgence is  fraught  with  mischief  to  both  parties.  It 
weakens  the  semen.  In  other  words,  this  is  not  so  rich 
in  spermatozoa  after  too  great  indulgence ;  and  when 
carried  to  the  extent  of  a  debauch,  the  fluid  ejected  may 
be  wholly  destitute  of  spermatozoa.     Thus  it  will  be 


SPERMATOZOA.  3^3 

seen  that  it  13  much  better  to  husband  the  resources  of 
both  man  and  wife.  The  sexual  act  should  never  be 
done  except  at  the  spontaneous  prompting  of  nature. 
It  is  very  curious  to  contemplate  the  bounties  of  nature 
when  we  come  to  view  the  provisions  made  for  fructifi- 
cation, whether  in  the  vegetable  or  animal  kingdom. 
We  know  that  but  little  semen  and  but  few  spermatozoa 
are  needed  for  fertilizing  the  ovum.  We  see  this  in  pis- 
ciculture, and  we  may  infer  it  in  all  creation.  I  do  not 
know  that  any  one  has  ever  thought  of  measuring  the 
quantity  of  semen  ejected  in  the  act  of  copulation,  nor 
do  I  know  that  it  would  be  possible  to  arrive  at  this 
point  accurately ;  but  accident  led  me  to  make  some  ob- 
servations on  this  subject,  which  I  here  place  on  record 
as  a  matter  of  physiological  interest,  if  not  of  therapeu- 
tical importance. 

In  most  women  a  considerable  part  of  the  semen 
passes  off  with  the  completion  of  the  copulative  act,  and 
the  separation  of  the  sexes,  while  a  large  part  of  it  re- 
mains in  the  vagina  to  gradually  ooze  away.  It  has  so 
happened  that  I  had  two  patients  whose  vaginas  seemed 
to  hold  almost  all  that  they  received.  It  has  been  my 
duty  to  examine  them  a  few  minutes  after  coition,  and 
the  perineum  and  nates  appeared  to  be  almost  as  dry  as 
if  nothing  of  the  kind  had  taken  place.  The  quantity 
of  semen  retained  by  the  vagina  seemed  to  me  to  be  so 
great,  that  I  was  induced  on  several  occasions  to  remove 
it  with  a  syringe,  and  to  measure  it  subsequently,  and  I 
found  that  ordinarily  there  was  about  a  drachm  and  ten 
minims.  Of  course,  this  did  not  comprise  all  that  was 
deposited  there,  for  a  very  considerable  portion  must  of 
necessity  always  be  removed  by  the  male,  merely  by  the 
attraction  of  cohesion. 

It  would  be  important  to  determine  how  long  sper* 


374  UTERINE    SURGERY. 

matozoa  can  live  in  the  matrix.  On  this  point  we  need 
more  extended  experiments,  for  I  do  not  think  that  their 
duration  of  life  has  yet  been  fully  established.  Dr.  S. 
R.  Percy,*  of  New  York,  reports  a  case  in  which  he  found 
"living  spermatozoa,  and  many  dead  ones,"  issuing  from 
the  OS  uteri,  eight  and  a  half  days  after  the  last  sexual 
connection.  During  this  time  the  husband  of  the  pa- 
tient had  been  from  home. 

I  have  examined  the  semen  many  times  with  the  view 
of  determining  this  point,  and  think  I  can  safely  say 
that  spermatozoa  never  live  more  than  twelve  hours  in 
the  vaginal  mucus.  But  in  the  mucus  of  the  cervix  they 
live  much  longer.  At  the  end  of  twelve  hours,  while 
all  are  dead  in  the  vagina,  there  are  but  few  dead  ones 
to  be  found  in  the  cervix.  When  the  cervical  mucus  is 
examined  from  thirty-six  to  forty  hours  after  coition,  we 
shall  ordinarily  find  as  many  spermatozoa  dead  as  alive. 
But  my  observations  on  this  point  could  not,  under  the 
nature  of  things,  be  accepted  as  the  rule,  for  they  were 
all  made  upon  those  who  were,  or  had  been,  the  subjects 
of  uterine  disease  in  some  form  or  other. 

Here  is  the  report  of  an  observation  made  upon  a 
patient  who  is  perfectly  reliable: — "Sexual  intercourse 
at  eleven  ]3.m.  on  Saturday.  A  microscopic  examina- 
tion of  the  secretions  was  made  on  Monday,  at  three 
p.m.,  just  forty  hours  afterwards.  The  vaginal  mucus 
contained  a  few  dead  spermatozoa — none  alive ;  the  cer- 
vical mucus  contained  great  numbers  very  active — a  few 
dead." 

The  above  is  copied  from  notes  made  at  the  time.  I 
saw  no  reason  why  many  of  these  active  spermatozoa 
should  not  have  lived  for  a  still  longer  time.     Many  of 

*  American  Medical  limes,  Mai'ch  9th,  1861. 


SPERMATOZOA.  375 

tliem  lived  six  hours  after  their  removal.  This  was  in 
July. 

Before  closing  this  subject,  I  shall  give  a  few  exam- 
ples illustrating  the  best  time  for  sexual  congress  after 
menstruation,  to  insure  conception. 

A  menstruation  took  place  on  the  Tth  and  ended  on 
the  10th  of  the  month.  Sexual  intercourse  happened 
once  on  the  11th.  On  the  morning  of  the  12th,  the 
lady  went  to  a  sea-side  watering-place,  where  she  remain- 
ed more  than  a  month,  leaving  her  husband  at  home. 
She  had  always  been  regular,  but  her  period  did  not 
appear  on  the  5th  of  the  following  month  as  she  expect- 
ed. Fearing  that  the  sea-bathing  had  something  to  do 
with  the  non-appearance  of  the  menses,  she  sent  for  a 
physician,  who  ordered  her  to  stop  the  baths,  and  gave 
her  some  strong  emmenagogues  to  provoke  the  flow,  but 
it  did  not  come.  The  next  period  passed,  and  it  was 
found,  greatly  to  her  surprise,  that  she  was  pregnant. 
She  went  the  full  time,  and  a  son  was  born. 

I  operated  on  a  lady,  thirty  years  old,  who  had  been 
married  fifteen  years  without  offspring.  I  directed  her 
to  have  sexual  intercourse  on  the  third,  fifth,  and  seventh 
days  after  the  cessation  of  the  menses.  She  menstruat- 
ed on  the  8th  of  the  month,  ceased  on  the  12th,  had 
sexual  intercourse  on  the  17th,  and  a  son  was  born  on 
the  16th  nine  months  afterwards. 

In  the  case  of  uterine  injection  spoken  of  on  page  368, 
menstruation  began  on  the  2d  of  the  month,  finished  on 
the  6th,  sexual  intercourse  took  place  on  the  12th,  the 
uterine  injection  was  only  five  or  six  minutes  afterwards, 
and  conception  dated  from  that  time. 

Here,  then,  is  one  case  where  conception  occurred  on 
the  day  after  the  flow  ceased,  and  only  four  days  from 
the  time  it  began ;  another  in  wliich  it  probably  took 


376  UTERINE  SURGERY. 

place  five  days  after  the  flow  ceased,  and  nine  days 
from  the  time  it  began ;  and  another  in  which  it  took 
place  six  days  after  the  flow  ceased,  and  ten  days  after 
it  began.  I  might  give  other  facts  like  the  last  two,  but 
I  forbear.  They  accord  very  well  with  the  received 
doctrines  of  the  day  as  to  the  proper  time  for  concep- 
tion, viz.,  about  a  week,  more  or  less,  after  the  cessation 
of  the  flow. 

I  hope  I  have  said  enough  to  show  that,  for  the  pur- 
pose of  conception,  "semen  with  living  spermatozoa 
should  be  deposited  in  the  vagina  at  the  proper  time." 


SECTION    Tin. 


THE  SECRETIONS  OF  THE  CERVIX  AND  VAGINA 

SHOULD  NOT  POISON  OR  KILL  THE 

SPERMATOZOA. 


SECTION  yiii. 

THE   SECRETIOI^S    OF   THE    CERVIX   AND    VAGINA    SHOULD 
NOT   POISON    OR    KILL   THE   SPERMATOZOA. 

The  vagina  and  the  canal  of  the  cervix  each  secrete  a 
mucus  peculiar  to  itself.  That  of  the  vagina  is  acid; 
that  of  the  cervix  very  slightly  alkaline.  These  secre- 
tions become  changed  in  character  and  consistence  by 
any  inflammatory  action  set  up  in  the  glandular  appara- 
tus that  gives  rise  to  them.  We  shall  consider  their 
deviations  from  a  normal  condition, 

1st.  Of  the  vaginal  secretions ;  and 

2nd.  Of  the  cervical. 

1.  The  vagina  is  subject  to  an  inflammatory  action, 
which  may  arise  from  a  specific  cause  or  not. 

Vaginitis  is  a  most  troublesome  affection ;  it  matters 
not  from  what  caaje  it  originates.  It  usually  has  a  spe- 
cific origin,  but  it  may  arise  spontaneously ;  sometimes 
it  is  secondary  to  some  irritating  discharge  from  the 
uterus.  Sir  Charles  Locock*  says:  "There  is  one  ma- 
terial point  connected  with  leucorrhoea,  and  especially 
where  the  discharge  is  purulent  or  of  an  acrid  charac- 
ter. In  such  instances  it  is  well  known  that  sexual  in- 
tercourse will  often  bring  on  a  train  of  symptoms  very 
much  resembling  gonorrhoea  in  the  male.  This,  when 
occurring  between  husband  and  wife,  has  often  led  to 
much  domestic  unhappiness,  from  the  supposition  of  one 


*  "  Cyclopaedia  of  Practical  Medicine."  article  Leucorrhoea. 


380  UTERIXE    SURGERT. 

party  or  the  other  having  contracted  gonorrhoea  from 
impure  connection." 

I  am  unhappily  able  to  substantiate  fully  all  that  is 
here  stated  on  this  point  by  this  distinguished  authority; 
for  I  have  seen  many  cases  of  urethral  inflammation  in 
the  husband,  that  were  unquestionably  contracted  from 
the  wife,  who,  however,  had  merely  a  leucorrhoea  of  an 
acrid  character. 

The  treatment  of  vaginitis  is  now  reduced  to  great 
simplicity.  I  have  found  Demarquay's  plan  to  answer 
admirably.  It  consists  in  introducing  a  tampon  of  cot- 
ton or  lint  saturated  with  a  solution  of  tannin  in  glyce- 
rine, from  two  to  four  drachms  to  the  ounce.  This  di-ess- 
iug  may  be  retained  three  or  four  days.  According  to 
Demarquay,  the  average  time  of  treatment  by  this 
method  is  about  a  fortnisrht. 

Recently  Dr.  John  J.  Black,*  of  the  Philadelphia 
Hospital,  Blockley,  has  made  some  experiments  in  the 
treatment  of  vaginitis  with  medicated  suppositories  that 
produced  most  satisfactory  results.  He  experimented 
with  persulphate  of  iron,  alum,  tannin,  copaiba,  and  a 
variety  of  other  remedies,  and  arrived  at  the  conclusion 
that  the  suppository  plan  of  treatment  was  superior  to 
all  other  methods  in  efficiency,  cleanliness,  portability, 
and  ease  of  application  at  any  time,  and  without  the  aid 
of  instruments.  Subjoined  is  one  of  Dr.  Black's  formu- 
lae for  their  preparation : 

3     OL  Theobromse,  3  xii. 

Morphias  Sulph.,  gr.  vi. 

Liq.  Ferri  Persulph.,  gtt.  cxliv. 

Cerat.  Adipis,   3  iij  ss. 
M     Et  fiant  Suppositoria  xii. 


*  American  Journal  of  the  Medical  Sciences,  No.  XCIX.   July  ,1865,  p.  63. 


VAaiNiTia  38X 

Of  these,  one  is  to  be  introduced  into  the  vagina 
every  other  day,  except  during  menstruation.  Dr.  Bhick 
says :  "  The  average  number  of  days  required  for  the  cure 
was  as  follows : — Liq.  ferri  persulph.,  nine  days ;  alum 
and  tan-nin,  nine  days  and  a  half;  ol.  copaibae,  twelve 
days ;  comp.  iodine  ointment,  thirteen  days ;  citrine  oint- 
ment, fourteen  days ;  chloride  of  zinc,  nineteen  days.'' 
The  very  strong  preparations  were  inferior  to  the  milder. 

This  is  certainly  far  better  than  the  old  plan  by  ni- 
trate of  silver  and  vaginal  washes,  which  was  always 
tedious  and  most  unsatisfactory.  I  do  not  know  that 
vaginitis,  properly  speaking,  is  absolutely  opposed  to 
the  vitality  of  the  spermatozoa.  According  to  Donne 
they  Uve  in  pus  and  blood,  and  a  variety  of  other  fluids. 
I  have  frequently  seen  conception  to  happen  where  the 
cervix  uteri  was  the  seat  of  profuse  suppuration,  so  that 
pus,  ^er  6-6,  is  no  hindrance  of  this.  The  most  trouble- 
some obstacle  of  this  sort  is  to  be  found,  not  in  the 
quantity  but  in  the  character  of  the  vaginal  secretion. 
This,  as  before  stated,  should  be  slightly  acid;  if  it  is 
very  acid  it  kills  the  spermatozoa  instantly.  I  have  seen 
many  cases  in  which  they  were  all  dead  within  five  or 
six  minutes  after  coition.  In  all  these  cases  the  vaginal 
mucus  was  by  no  means  abundant,  but  the  surface  of  the 
vagina  always  had  a  reddish  look,  and  its  papillae  were 
prominent. 

By  simply  inspecting  the  surface  of  the  vagina,  and 
testing  the  degree  of  acidity  with  litmus-paper,  I  have 
sometimes  been  able  to  say  that  the  vaginal  mucus  would 
probably  poison  the  sj)ermatozoa.  The  blue  litmus 
should  be  slowly  turned  to  a  faint  pink  when  the  secre- 
tion is  normal;  but  when  it  is  abnormal,  the  litmus-paper 
turns  quickly  to  a  deeper  pink  colour.  I  have  seen  con- 
ception twice  where  the  vaginal  mucus  poisoned    the 


582  UTERINE  SURGERY. 

Bpermatozoa.  One  was  remedied  by  sliglitl}^  alkaline 
washes  used  before  sexual  congress.  In  the  other  it  oc- 
curred in  this  way.  A  lady,  aged  twenty-eight,  was 
married  six  years  without  issue.  She  had  a  contracted 
OS.  It  was  incised ;  but  she  did  not  conceive.  She  had 
an  indurated  cervix,  the  consequence  of  cystic  disease. 
For  this  she  was  under  treatment  for  nearly  two  months. 
It  was  cured ;  and  her  husband  came  to  take  her  home. 
Wishing  to  see  the  character  of  the  semen,  I  examined 
the  vaginal  mucus  four  or  five  hours  after  coition.  The 
spermatozoa  were  all  dead.  On  the  next  day  I  examined 
them  in  five  or  six  minutes  afterwards,  and  could  not  find 
one  alive.  I  then  placed  in  the  vagina  a  small  tampon 
of  cotton  moistened  with  a  little  glycerine,  which  held 
in  solution  some  of  the  bicarbonate  of  soda  (twenty 
grains  to  the  ounce).  This  application  was  repeated  on 
the  next  day.  The  cotton  was  tied  with  a  string  for  its 
easy  removal.  This  was  worn  from  about  two  o'clock 
p.m.  till  eight  the  next  morning.  Its  removal  was  fol- 
lowed by  connection.  Living  spermatozoa  were  after- 
wards found  in  the  greatest  abundance.  Indeed,  there 
were  no  dead  ones  at  all.  Conception  dated  from  that 
moment,  being  just  two  days  before  the  expected  return 
of  the  menses,  which,  however,  did  not  recur.  There 
had  been  no  sexual  intercourse  for  nearly  two  months 
before.  Labour  came  on  at  the  fulness  of  time ;  and 
the  delivery  was  safe. 

According  to  Kolliker,  the  phosphate  of  soda  is 
peculiarly  favourable  to  the  movements  of  spermatozoa ; 
and  this  would  probably  be  a  good  application  in  such 
cases  as  the  above.  But  as  yet  I  have  had  no  experience 
with  it. 

2.  Of  cervical  leucorrhcea. 

Dr.  Bennet  has  done  much  for  the  treatment  of  the 


LEUCOB,RH(EA.  333 

diseases  of  the  cervix  uteri ;  and  Dr.  Tyler  Smith's 
contributions  to  the  Pathology  of  Leucorrhoea*  are 
of  the  greatest  importance.  With  these  and  the  com- 
prehensive treatises  of  West,  of  Churchill,  of  Hewitt, 
and  of  McClintock  now  before  us,  and  all  fresh  from 
the  press,  I  can  here  afford  to  pursue  pretty  much  the 
same  course  as  that  which  I  have  followed  all  along, 
viz.,  to  give  a  few  clinical  illustrations  of  merely  surgical 
and  manipulatory  processes. 

Cervical  leucorrhoea  may  be  a  hyper-secretion  from 
the  lips  of  the  os,  or  from  the  cavity  of  the  cervix.  It 
is  almost  always  of  albuminous  consistence,  and  very 
difficult  of  removal.  Under  the  microscope  it  presents 
the  characteristics  of  muco-j)us.  Sometimes  it  is  merely 
an  exaggerated  secretion  seemingly  without  any  abnor- 
mal qualities.  It  interferes  with  conception  in  two 
ways — mechanically  and  chemically.  Mechanically  in 
blocking  up  the  canal  of  the  cervix,  and  preventing  the 
passage  of  the  spei-matozoa ;  chemically  by  poisoning 
or  killing  them.  I  have  frequently  seen  conception 
happen  while  using  the  nitrate  of  silver  for  granular 
erosion  of  the  os  and  cervix  uteri.  Unless  there  is 
some  special  reason  for  it,  I  never  interdict  sexual 
congress  during  the  treatment  of  ordinary  cases  of  cer- 
vical engorgement.  Where  conception  has  taken  place 
under  these  circumstances,  I  am  satisfied  that  sexual 
intercourse  must  have  occurred  within  ten  or  twelve 
hours  after  the  use  of  the  remedy,  or  at  least  before  its 
eschar  began  to  separate,  which  is  always  attended  with 
a  secretion  of  muco-pus  that  would  be  fatal  to  the 
spermatozoa. 


*  "The  Pathology   and    Treatment  of  Leucorrhoea."      By  W.  Tyler 
Smith,  M.D.,  Professor,  &c.,  1855. 


334  UTERINE    SURaERT. 

Nitrate  of  silver  will  probably  retain  tbe  good  repa* 
tation  it  has  acquired  in  tlie  treatment  of  granular 
erosions  of  the  cervix.  In  some  cases  it  unfortunately 
provokes  haemorrhage,  and  this  is  one  of  the  objections 
to  its  use.  Dr.  Wright,*  of  the  Samaritan  Hospital, 
has  recently  called  the  attention  of  the  profession  to 
the  use  of  a  compound  of  the  iodide  and  nitrate  of 
silver  as  they  exist  in  "  an  old  photographic  nitrate- 
baili,  still  bright  and  clear,  but  which  had  been  so  long 
worked  that  it  had  become  saturated  with  iodide  of 
silver,  and  contained  a  considerable  amount  of  ether." 
Accident  led  him  to  the  use  of  this  preparation,  and 
he  has  found  it  far  more  efficacious  in  the  various 
forms  of  stomatitis  and  analogous  affections  of  the 
uterus  than  the  more  concentrated  solutions  of  the  pure 
nitrate  of  silver.  Dr.  Gibb  has  also  used  it  topically 
with  marked  benefit  in  affections  of  the  throat  and 
larynx.  This  "  old  bath  solution  "  may  be  obtained  of 
any  respectable  photographer. 

I  know  of  no  caustic  application  of  more  value  in 
these  cervical  engorgements  than  the  chromic  acid,  as 
already  set  forth  on  page  43. 

Potassa  cum  calce  1  now  seldom  employ,  and  think 
it  should  be  used  with  great  caution.  In  the  practised 
hands  of  such  men  as  Bennet  and  Tilt  I  have  no  fear  of 
it.  We  know  very  well  that  we  can  by  long  experience 
acquire  a  tact  in  the  management  of  powerful  remedies 
whereby  they  are  perfectly  harmless.  Any  one  must 
have  been  struck  with  this  fact  who  has  followed  the 
distinguished  surgeon  Jobert  (de  Lamballe)  through 
his  wards  in  the  Hotel  Dieu,  and  seen  with  what  skill 


*  The  Lancet,  March  18,  1865,  p.  282  :    "  The  Topical  Use  of  Silver  Solu- 
tions."     By  Henry  Gr.  Wright,  M.D. 


LEUCORRHCEA.  3§5 

he  wielded  the  potential  cautery  in  the  kind  of  cases 
that  we  are  now  considering. 

There  are  many  hypertrophied  and  granular  condi- 
tions of  the  cervix  that  obstinately  resist  all  local  stimu- 
lating, or  escharotic  applications.  Scanzoni  recommends 
excision  or  amputation  of  the  affected  portion  when  this 
is  the  case.  For  many  years  I  have  been  in  the  habit 
of  doinsr  this,  and  have  thus  often  cured  cases  in  a  week 
o]'  a  fortnight  that  had  been  under  treatment  for  months 
without  improvement. 

Vaginal  washes  are  of  some  importance  in  the  con- 
ditions of  the  cervix  that  give  rise  to  leucorrhoeal  dis- 
charges. They  are  to  be  made  with  a  syringe  that  is 
capable  of  throwing  in  a  sufficient  quantity  of  water 
without  fatigue  to  the  patient.  Solutions  of  alum,  of 
zinc,  of  lead,  of  iron,  of  tannin,  and  of  other  astringent 
remedies,  may  be  used  from  time  to  time.  We  should 
never  use  cold  va2:inal  washes.  I  am  sure  I  have  seen 
great  harm  produced  by  them.  They  are  valuable  in 
controlling  leucorrhoeal  discharges,  but  they  favour  to  a 
great  degree  the  production  of  an  indurated  condition 
of  the  cervix,  wdiich  is  to  be  avoidcvl  if  possible.  Vagi- 
nal injections  should  always  be  tepid,  let  them  contain 
what  they  may  in  solution. 

It  has  been  thought  that  they  could  produce  but 
little  effect  on  the  condition  of  the  cervix ;  but  this  is  a 
great  mistake.  Kemedies  thus  applied  act  by  osmosis, 
and  produce  not  only  a  local,  but,  in  aome  instances,  a 
constitutional  effect.  I  have  often  heard  patients  com- 
plain of  the  taste  of  tannin  a  few  minutes  after  its 
application  to  the  cervix  uteri.  It  might  be  supposed 
that  this  was  an  effect  of  imagination,  or  that  the 
odour  of  it  was  confounded  wdth  the  taste.  But  this 
could  not  be  so,  when  the  application  was  made  without 

25 


ggg  UTERINE    SURGERY. 

the  patient  knowing  what  it  was ;  and  if  the  scent  of 
it  was  mistaken  for  the  taste,  the  mother,  or  aunt,  or 
nurse  present  would  have  been  as  liable  to  be  thus 
deceived  as  the  patient,  which  was  never  the  case. 
I  am  perfectly  satisfied  that  I  have  known  patients 
to  experience  the  taste  of  tannin  in  the  mouth  only 
two  or  three  minutes  after  it  was  applied  to  the  cervix 
uteri. 

Great  care  is  necessary  in  the  use  of  the  syringe. 
How  often  have  I  seen  vaginal  injections  given  without 
their  ever  reaching  the  posterior  cul-de-sac ;  occa- 
sionally not  even  the  anterior.  Why  any  one  should 
ever  have  made  a  curved  vaginal  tube  I  cannot  under- 
stand ;  and  yet  we  find  them  in  all  the  shops.  If  a 
curved  tube  be  introduced  into  the  vagina  with  its  con- 
cavity upwards  the  distal  end  will  strike  against  the 
anterior  wall  of  the  vagina  before  it  reaches  the  cervix 
uteri ;  if,  on  the  contrary,  it  be  turned  backwai'ds,  it 
will  as  invariably  rest  upon  the  posterior  wall  of  the 
vagina  without  passing  under  the  cervix,  and  in  either 
case  it  fails  totally  in  the  object  of  its  use.  A  vaginal 
syringe  tube  should  be  about  the  size  of  the  little  finger, 
and  full  four  inches  long.  The  patient  should  be  taught 
to  use  it  for  herself.  It  should  be  passed  into  the 
vafriua,  and  directed  downwards  and  backwards  as  if  it 
were  to  be  passed  in  the  direction  of  the  os  coccygis. 
It  should  be  pushed  gently  on  almost  by  its  own  gravity, 
if  the  patient  is  in  the  recumbent  posture,  till  it  seems 
to  be  arrested  by  an  elastic  resistance,  which  is  the 
posterior  cul-de-sac.  We  shall  then  know  that  the 
end  of  the  tube  is  under  and  beyond  the  cervix  uteri. 

When  we,  then,  begin  to  inject  the  water,  we  shall 
feel  confident  that  it  will  in  its  regurgitation  bring  away 
whatf ver  secretions  may  be  lying  in  the  vagina,  whether 


VAGINAL   INJECTIONS.  3S7 

high  up  or  low  down.  We  cannot  be  too  careful  in  oui 
directions  about  the  use  of  vaginal  washes,  for  if  not 
properly  applied  they  may  not  only  fail  to  accomplish 
all  that  we  expect  from  them,  but  they  may  produce 
most  painful  if  not  dangerous  consequences.  We  all 
know  what  a  serious  matter  it  once  was  to  throw  the 
blandest  fluid  into  the  cavity  of  the  uterus  ;  indeed, 
many  of  us  had  altogether  given  up  the  practice  of 
injecting  this  cavity  with  any  fluid  whatever  till  Dr. 
Savasre  showed  how  safe  it  was  after  the  dilatation  of 
the  OS  internum  by  sponge  tents.  The  accident  that  I 
allude  to  as  sometimes  happening  from  the  use  of  the 
vaginal  syringe  is  that  of  suddenly  throwing  a  jet  of 
water  forcibly  into  the  cavity  of  the  uterus,  which  pro- 
duces a  dreadful  uterine  colic,  attended  with  the  -most 
distressing  symptoms  of  prostration.  'No  man  who  has 
unfortunately  witnessed  the  perfect  collapse  following 
such  an  occurrence,  whether  by  accident  or  design,  can 
ever  forget  the  feeling  of  dread  that  seized  his  own  soul 
as  he  saw  his  patient  launched  in  a  moment  from  a  com- 
parative state  of  ease  and  comfort  into  the  very  jaws  of 
death,  as  it  were.  I  have  never  known  any  one  to  die 
as  a  consequence  of  uterine  injecdon,  but  he  is  a  rash 
man  who  runs  the  risk  of  his  patient's  life  after  once 
witnessing  the  painful  results  of  such  a  thing  under  the 
old  regime. 

The  uterine  colic  accidentally  produced  by  the  self- 
injecting  syringe  has  always  happened  under  my  obser- 
vation in  cases  of  retroversion.  In  these,  the  os  tincSB 
presented  in  the  line  of  the  axis  of  the  vagina ;  the  end 
of  the  tube  entered  the  open  os,  and  the  water  was 
thrown  directly  into  the  cavity  of  the  uterus.  It  is, 
therefore,  most  important  in  cases  of  retroversion,  to 
teach  the  patient  the  art  of  using  the  syringe  properly 


388  UTERINE  SURGERY. 

and  safely  as  well  as  efficiently.  To  prevent  any  acci- 
dent it  would  be  well  to  close  the  little  hole  in  the  end 
of  the  tube,  leaving  the  lateral  ones  open. 

Amongst  other  vaginal  washes  for  cervical  secretions^ 
I  must  not  omit  to  mention  Dilute  Hydrochloric  Acid. 
I  gave  Mr.  Swann,  of  Paris,  several  samples  of  muco- 
purulent albuminoid-looking  secretions  from  the  cervical 
cavity,  for  experimental  observation,  and  he  found  that 
dilute  hydrochloric  acid  was  the  only  chemical  capable 
of  dissolving  it,  that  could  be  used  locally  as  a  wash. 
Where  there  is  no  vaginal  irritation  or  epithelial  abra- 
sion, this  may  be  used  with  advantage  according  to  the 
following  formula : — 

5     Dilute  Hydrochloric  Acid,  §  j. 
,  Distilled  water,  3  vij. 

A  tablespoonful  in  a  pint  of  tepid  water  to  he  thrown  into  the  vagina 
night  and  morning. 

But  vaginal  injections  are  only  adjuvants  of  treat- 
ment. We  cannot  depend  upon  them  wholly  for  cura- 
tive results.  They  are  valuable  in  their  way,  and  not  to 
be  ignored.  I  know  of  nothing  more  difficult  of  cure 
than  an  old  cervical  leucorrhoea ;  and  notwithstanding 
the  vaunted  success  of  this  or  that  remedy,  I  fear  that 
the  young  practitioner  will  often  be  disappointed  in  their 
application. 

Professor  Courty,  of  Montpelier,  foiled  in  the  treat- 
ment of  cervical  leucorrhoea  by  the  ordinary  routine, 
resorted  to  the  expedient  of  leaving  a  bit  of  nitrate  of 
silver  in  the  canal  of  the  cervix  for  several  days,  and 
describes  good  results  from  it.  Dr.  Simpson  has  lately 
been  applying  various  remedies  in  the  vagina  in  the  form 
of  suppositories,  made  of  the  butter  of  cocoa.     I  have 


VAGINAL    INJECTIOUa  3S9 

recently  had  made  little  suppositories  of  cocoa  butter,  an 
inch  and  a  quarter  long,  and  small  enough  to  pass  along 
the  cervix,  medicated  with  various  remedies  so  as  to 
bring  these  into  permanent  contact  with  the  diseased 
surface.  -  For  instance,  I  have  had  them  made,  contain- 
ing severally  morphine,  ati'opine,  alum,  tannic  acid, 
persulphate  of  iron,  &c.,  in  appropriate  doses,  and  thinli 
they  promise  very  satisfactoiy  results. 

A  very  convenient  way  of  applying  remedies  topi- 
cally to  the  cervix  uteri  is  that  introduced,  I  believe,  by 
Kiwisch,  of  using  a  tampon  of  cotton  or  lint,  saturated 
wi+h  a  solution  of  the  remedy  to  be  so  used.  I  have  for 
a  long  time  adopted  this  plan,  and  have  every  reason  to 
be  satisfied  with  it. 

If  I  were  asked  what  next  to  mere  mechanical 
obstruction  of  the  cervix  uteri  constitutes  the  greatest 
obstacle  to  conception,  I  would  have  no  hesitation  in 
saying  that  it  was  an  abnormal  secretion  from  the 
cervix. 

We  often  see  the  cervical  mucus  in  such  large  quan- 
tities that  its  mere  abundance  will  mechanically  prevent 
the  passage  of  the  semen  to  the  cavity  of  the  uterus. 
Sir  Joseph  Olliffe  has  informed  me  of  the  case  of  the 
wife  of  a  medical  man,  who  had  been  sterile  for  many 
years,  and  whose  cervix  uteri  always  presented  a  little 
mass  of  ropy  mucus  hanging  from  the  os  that  obstructed 
mechanically  this  canal.  At  last,  the  doctor  had  the 
rational  surgical  idea  to  exhaust  the  cervix  of  its  inspis- 
sated mucus,  and  sexual  cono;ress  with  his  wife  immedi- 
ately  afterwards  was  followed  by  conception. 

I  knew  but  little  about  the  effects  of  the  mucous 
secretion  of  the  vagina  and  the  cervix  upon  the  vitality 
of  the  spermatozoa  until  within  the  last  three  or  four 
years;  and  I  am  now  satisfied  that  the  cervical  secre- 


390  UTERINE    SUHGEEY. 

tion  is  often  poisonous  to  the  spermatozoa,  even  when  it 
would  seem  to  be  almost  normal  in  appearance.  This 
must  depend  upon  some  other  quality  than  mere  alka- 
linity, for  I  have  often  found  all  the  spermatozoa  in  the 
cervical  mucus  dead  while  it  manifested  no  unusual 
degree  of  alkalinity  when  tested  by  litmus-paper.  But 
when  placed  under  the  microscope  it  showed  an  uncom- 
mon number  of  epithelial  scales.  This  demonstrated 
an  abnormal  action  in  the  glandular  apparatus  that 
gave  rise  to  this  secretion,  which  seemed  to  kill  the 
spermatozoa  more  by  its  density  than  by  its  chemical 
action ;  for  I  have  noticed  that  they  lived  longer  in 
that  portion  of  the  mucus  that  had  the  fewest  number 
of  epithelial  scales  ;  and,  vice  versa,  died  quicker  in 
that  portion  that  had  the  most;  and  that,  too,  when 
litmus-paper  showed  no  difference  in  the  chemical 
character  of  the  two. 

In  these  cases,,  in  almost  every  instance  after  the  use 
of  a  sponge-tent,  for  six  or  eight  hours  I  have  been  able 
to  detect  by  the  sense  of  touch  a  small  gristly  growth 
at  some  point  in  the  course  of  the  canal  of  the  cervix 
that  was  evidently  the  seat  of  this  abnormal  hyper- 
secretion. Sometimes  this  is  confined  to  a  single  spot ; 
again,  it  may  be  spread  over  a  surface  of  greater  or  less 
extent.  Occasionally  the  whole  of  the  lining  membrane 
of  the  canal  may  be  a  muco-pyogenic  surface.  What 
are  we  to  do  vvhen  this  is  the  case?  As  said  before,  I 
know  of  nothing  more  difficult  to  remedy.  Professor 
Courty's  plan  of  prolonged  cauterization  may  hold  out 
some  hopes  of  a  cure ;  or  the  method  of  intra-cervical 
suppositories  already  alluded  to  ma)^  be  of  service.  But 
I  am  disposed  to  believe  that  we  shall  do  better  by  ignor- 
ing caustics  and  caustic  applications  altogether,  and 
resorting  to  some  method  of  modifying  this  secretory 


ENDO-CERTICITIS.  39  ] 

surface  by  }3ressure.  My  countryman,  Professor  Byford* 
speaking  of  Endocervicitis,  says:  "A  bougie  of  slippery 
elm  large  enough  to  fill  the  cervical  cavity,  introduced 
as  high  as  the  inflammation  extends,  and  allowed  to  re- 
main for  twenty-four  or  thii'ty-six  hours,  not  only  prepares 
the  way  for  other  applications,  but  favourably  modifies 
the  disease  by  its  pressure  upon  the  capillaries.  The 
use  of  the  stem  pessary  proves  beneficial  too,  I  think,  in 
some  instances,  on  account  of  the  stem  pressing  upon  the 
inflamed  part  inside  the  cavity  of  the  cervix,  and  thus 
changing  the  character  of  the  capillary  action." 

I  am  quite  prepared  to  accept  Pi'ofessor  Byford's 
teachings  on  this  point,  for  I  have  known  many  cases  of 
conception  to  follow  the  use  of  the  intra-uterine  stem, 
and  I  have  now  but  little  doubt  that  its  curative  action 
was  more  in  relieving  that  condition  of  the  cervical 
membrane  that  gave  rise  to  abnormal  secretions,  than  in 
merely  mechanically  dilating  the  os  internum. 

I  have,  in  the  early  part  of  this  volume,  objected  to 
the  use  of  the  intra-uterine  stem ;  but  there  is  a  modifi- 
cation of  it  by  Dr.  Greenhalgh  that  I  have  occasionally 
used  with  good  results.  Its  advantage  over  its  proto- 
type is,  that  it  is  tubular  and  self-retaining.  It  allows 
the  secretions  from  the  cavity  of  the  uterus  to  pass 
through  it,  and  at  the  same  time  it  is  not  so  liable  to 
slip  out. 

Fig.  142  represents  the  instrument  of  full  size.  It  is 
from  two  to  two  inches  and  an  eis^hth  lons^.  It  is  intro- 
duced  with  the  wings  drawn  into  a  straight  line  by 
means  of  a  stilet,  as  shown  in  the  figure.     As  soon  as 


*  "  The  Practice  of  Medicine  and  Surgery,  applied  to  the  Diseases  and  Ac- 
cidents incident  to  "Women."  By  Wni.  H.  Byford,  M.A.,  il.D.,  Professor, 
&c.    Pliiladolphia :     Lindsay  &  JBlakiston.     1865.     Page  262. 


392 


UTERTNfe    SURGERY. 


it  is  passed  to  the  requisite  depth,  the  stilet  is  with 
drawn  ;  the  wings  spring  back  within  the  cavity  of  the 
^-■>  /^  "^^  uterus ;  the  os  internum  grasps  the  instru- 
Vx  H  V  raent  at  its  bifurcation,  and  the  lower  end 
rests  against  the  os  tincse.  Of  course,  this 
instrument  can  only  be  used  after  an  in- 
cision of  the  cervix  or  a  dilatation  of  it 
by  a  sponge  or  a  sea-tangle  tent.  It  may 
be  made  of  steel  and  silver  plated ;  but  1 
prefer  it  of  vulcanite.* 

I  have  seen  cases  in  which  this  instru- 
ment was  worn  with  great  comfoi't ;  and 
aoaiu  I  have  seen  others  that  could  not 
tolerate  its  presence  for  a  moment.  In 
these  last  we  shall  find  the  cause  of  into- 
lerance to  be  an  endo-metritis  which  had 
not,  perhaps,  been  suspected  before.  Dr 
Coghlan'sf  plan  of  using  a  tube  of  sheet- 
lead  I  have  found  to  answer  a  very  good 
purpose. 

I  have  not  been  able  to  arrange  any 
apparatus  for  withdrawing  in  an  isolated  form  the  secre- 
tions offthe  cavity  of  the  uterus  for  microscopic  and 
chemical  examination.  It  is  highly  probable  that  this 
will  be  done  at  some  time  or  other,  and  we  shall  then  be 
able  to  determine  more  about  the  condition  of  its  secre- 
tions as  influencing  the  life  or  death  of  the  spermatozoa. 
We  have  already  made  great  advances  in  studying  the 
effects  of  the  vaginal  and  cervical  secretions  upon  them ; 


Fig.  142. 


*  Made  by  Mayer,  of  Great  Portland  Street ;  also  by  Weiss. 

t  "  On  Dysmenorrhoea  and  Sterility ;  with  Wood-cuts  of  New  Instru- 
ments." By  John  C<  ghlan,  M.D.  Medical  Times  and  Gazette,  1861,  '62, 
and  '64. 


ENDOCERVICITIS.  393 

and  I  beloiiGf  to  that  saDiniine  class  of  medical  nie.j  who 
look  forward  with  great  Lope  to  enlai'ged  views  and 
more  certain  methods,  not  only  m  this  but  in  every 
department  of  medicine. 

1  have  said  a  good  deal  about  semen  and  its  exami- 
nation, and  it  is  time  that  I  should  say  something  about 
the  measures  preparatory  to  this.  Suppose  we  wish  to 
examine  the  vaginal  mucus  soon  after  coition — say  with- 
in an  hour;  we  direct  the  patient  to  empty  the  bladder 
before  the  act,  and  to  retain  quietly  the  recumbent  pos- 
ture after  it.  The  dorsal  decubitus  is  the  best.  To  re- 
move a  few  drops  of  the  contents  of  the  vagina,  pass  the 
indez  finger  into  it,  press  the  posterior  wall  downwards 
and  backwards,  just  under  the  cei'vix  uteri;  hold  it  so 
for  a  minute  or  two  ;  the  semen  will  necessarily  gravitate 
to  the  pouch  made  by  this  pressure ;  then  introduce  the 
nozzle  of  the  syringe  along  the  finger;  let  it  project 
slightly  over  the  end  of  the  finger-nail,  and  it  will  be 
easy  enough  to  obtain  what  we  want  if  there  is  any  se- 
men in  the  vagina.  I  am  thus  minute  in  explaining  this 
simple  operation,  because  we  may  fail  in  it  entirely,  even 
when  the  vagina  contains  large  quantities  of  semen,  if 
we  neglect  these  minutiae.  And  in  this  way.  If  we 
pass  in  the  syringe  in  a  haphazard  manner,  and  begin  to 
draw  the  piston,  the  mucous  membrane  of  the  vagina  is 
sucked  up  into  the  end  of  the  tube,  and  thus  it  is  possible 
for  us  to  slide  it  around  in  various  directions,  without 
getting  a  drop  of  mucus  of  any  sort.  But  suppose  we 
fiiil  even  with  properly  directly  efforts;  then  the  left 
lateral  position  and  my  speculum  will  in  a  moment  show 
us  the  whole  of  the  contents  of  the  vagina,  and  we  can 
with  the  svrinf^e  remove  what  we  want. 

When  we  wish  to  examine  the  cervical  mucus,  we 
should  resort  at  once  to  the  speculum  and  the  proper 


39-1  UTERINE    SURGERY. 

position.  It  is  well  eiiougli,  then,  to  sponge  away  ull 
the  mucus  from  the  vagina,  and  especially  from  about 
the  cervix  uteri.  We  then  pass  the  nozzle  of  the  syringe 
just  within  the  os  tincge,  and  draw  up  a  drop  of  its  mu- 
cus. To  do  this  it  is  necessary  first  to  pull  the  cervix 
forwards,  so  as  to  be  able  to  look  into  it  and  to  see  ex- 
actly what  we  are  doing.  If  the  cervical  mucus  is  very 
tenacious  we  may  fail  to  get  it  away.  Then  it  will  at 
the  next  attempt  be  necessary,  after  introducing  the 
syringe,  and  drawing  up  the  mucus,  to  pass  the  left  in- 
dex finger  to  the  edge  of  the  os  tincse,  and  slide  the  end 
of  the  syringe  on  to  the  end  of  the  finger  without  raising 
it  from  the  surface  of  the  cervix,  or  breaking  its  suction 
power.  This  may  seem  to  be  a  little  thing  to  describe 
so  minutely,  but  really  it  is  a  niost  important  matter  to 
know  and  to  do,  if  we  expect  to  be  exact  in  our  investi- 
gations. The  nicety  of  this  manipulation  renders  it  the 
more  important  for  us  to  clear  away  all  the  vaginal  mu- 
cus before  we  undertake  it,  lest  we  get  some  of  this 
drawn  up  into  the  syringe,  which  would,  of  course,  mar 
the  precision  of  our  observations. 

Suppose  we  succeed  in  this;  then  we  may  wish  to 
pass  the  syringe  up  for  an  inch  into  the  cervix  to  get  a 
portion  of  mucus  nearer  the  cavity  of  the  uterus.  This 
operation  is  quite  as  delicate  and  quite  as  important  as 
the  first,  and  is  to  be  conducted  in  the  same  way.  There 
is  an  object  in  having  the  end  of  the  syringe  bulb-shaped, 
as  represented  in  fig.  140.  This  bulb  fills  up  the  os  or 
the  canal  of  the  cervix,  and  prevents  the  air  from  beino- 
drawn  into  the  instrument,  as  sometimes  happened  with 
me  when  it  was  slender  and  more  pointed.  For  carry- 
ing a  fluid  of  any  sort  into  the  cavity  of  the  uterus, 
of  course  we  need  the  nozzle  of  the  syringe  more 
like    that   represented    in    fig.  141;   but    for    remov- 


CERVICAL    MUCUS.  395 

ing   anything  from   tlie   cervix   the  bulb  form  is  the 
best. 

As  illustrating  the  exactness  and  the  importance  of 
this  method  of  investigation,  I  will  give  an  example. 

Dr.  J*auvel,  the  distinguished  laryngoscopist,  of  Paris^ 
requested  me  to  see  a  patient  of  his,  who  had  been 
married  twice,  and  had  had  one  child  by  the  first  mar- 
riage ;  none  by  the  second.  She  was  thirty-five  years 
of  age,  the  picture  of  good  health,  and  menstruated 
regularly  and  normally.  The  uterus  was  slightly  ante- 
verted.  She  had  no  leucorrhoea,  properly  speaking ;  but 
the  cervical  mucus  seemed  to  be  slightly  in  excess  of  a 
normal  quantity.  What  was  the  cause  of  her  persistent 
sterility  for  the  last  eight  years,  and,  indeed,  for  the  last 
four  years  of  her  first  marriage  ? 

The  questions  to  be  answered  were.  Was  the  semen 
normal?  Did  the  secretions  of  the  vagina  or  cervix 
poison  the  spermatozoa  ?  Did  these  enter  the  canal  of 
the  cervix  ? 

The  vasrina  was  examined  an  hour  after  sexual  inter- 
course.  Its  mucus  contained  living  spermatozoa  in 
abundance.  The  cervical  mucus  was  full  of  them,  but 
they  weie  all  dead. 

On  another  occasion,  a  microscopic  examination 
made  but  a  few  minutes  (eight  or  ten)  after  coition, 
proved  tliat  the  mucus  of  the  cervical  canal  was  full  of 
dead  spermatozoa,  while  in  the  vagina  they  were  living. 
Here  the  litmus  test  was  valueless;  but  the  microscope 
demonstrated  a  superabundance  of  epithelial  casts,  the 
result  of  a  slightly  congested  condition  of  some  portion 
of  the  lining  membrane  of  the  cervix. 

As  said  before,  all  abnormal  secretions  from  the  va 
gina  have  been  classed  under  the  generic  term  leucor- 
rhoea, whether  they  emanate  from  the  vagina,  from   the 


396  UTERIS" E  SURGERY. 

canal  of  the  cervix,  or  fi'om  the  cavity  of  the  uterus. 
Having  ah'eacly  hurriedly  glanced  at  the  conditions  of 
the  first  two  that  ordinarily  give  rise  to  such  dischai'ges, 
it  only  remains  to  notice  those  of  the  third, — viz.,  the 
cavity  of  the  womb.  We  all  know  that  muco-pus  is  the 
almost  constant  accompaniment  of  polypus,  but  as  this 
has  already  been  the  subject  of  discussion  we  have  here 
nothing  more  to  say  on  it. 

The  cavity  of  the  uterus  sometimes  becomes  a  regu- 
lar abscess,  as  it  were.  This  condition  has  been  particu- 
larly described  by  Dr.  J.  Matthews  Duncan,  of  Edin- 
burgh. 

Dr.  West*  (p.  137)  says,  "A  peculiar  form  of  uterine 
leucorrhoea,  limited  in  its  occurrence  to  the  aged,  and 
associated  with  dilatation  of  the  cavity  and  atrophy  of 
the  walls  of  the  uterus,  has  been  described  by  Dr.  Mat- 
thews Duncan,  in  the  Edinhurgli  Medical  Journal^ 
March,  1860.  Its  characteristic  symptoms  appear  to 
be  peculiar  lumbar  and  pelvic  pain,  accompanied  by  a 
sense  of  constriction,  and  the  discharge  of  muco-pus. 
Its  cure  seems  to  require  the  dilatation  of  the  contracted 
internal  os  by  the  sound,  and  the  application  of  nitrate 
of  silver  to  the  interior  of  the  womb.  I  believe  that  I 
have  met  with  this  condition  on  one  or  two  occasions ; 
but  the  patients,  having  their  minds  relieved  with  refer- 
ence to  the  existence  of  uterine  cancer,  preferred  putting 
up  with  the  discomfort  to  submitting  to  treatment  for 
its  cure." 

I  have  seen  one  well-marked  case  of  this  sort.  The 
patient  was  about  sixty  years  of  age,  and  had  had  a 
purulent  discharge  from  the  vagina  for  twelve  months  or 


*  "  Lectures  on  the  D  seases  of  "Women."    By  Charles  West,  M.D.,  Fel- 
low, &c.     Tliird  EcUtion     1864. 


ENDO-MfiTEITIS.  39*^ 

more.  She  was  tlie  mother  of  a  large  family  of  grown- 
up children,  and  had  ceased  to  menstruate  at  aboui  forty- 
five.  The  discharge  from  the  vagina  was  pure  pus ;  and 
it  had  almost  a  cancerous  odour.  On  examination,  I 
found  the  vagina  full  of  pus,  and  its  whole  surface  and 
that  of  the  cervix  were  excoriated  and  granular.  The 
uterus  was  retroverted,  and  of  rather  unusual  size  for 
the  period  of  life.  I  did  not  detect  the  true  nature  of 
the  disease  for  some  time ;  not  till  I  had  succeeded  in 
restoring  the  vagina  and  the  cervix  to  a  perfectly  healthy 
condition.  Then  I  discovered  that  the  os,  which  was 
very  small,  gave  issue  to  a  slight  though  constant  dis- 
charge of  pus,  and  that  this  was  the  cause  of  the  vagi- 
nitis, which  I  had  mistaken  for  and  treated  as  the  origi- 
nal disease.  The  cervical  canal  was  very  narrow,  flexed, 
and  contracted  at  the  os  internum,  so  that  the  uterus,  as 
it  was  bent  backwai-ds,  always  held  about  an  ounce  of 
pus.  As  the  first  step  in  the  treatment,  the  cervix  was 
dilated ;  the  pus  was  then  evacuated ;  the  cavity  of  the 
uterus  was  washed  out  with  warm  water,  injected  through 
a  tube  small  enough  for  the  stream  of  water  to  regurgi- 
tate easily  by  its  side ;  and  then  the  pyogenic  cavity  was 
injected  sometimes  with  the  Tr.  of  Iodine,  and  some- 
times with  a  solution  of  the  Persulphate  of  Iron.  The 
patient  soon  began  to  improve,  and  was  finally  cured. 

We  can  thus  medicate  the  cavity  of  the  uterus  with 
the  greatest  safety,  if  we  are  only  careful  to  provide  an 
easy  retrogression  of  the  injected  fluid,  either  by  the 
sponge-tent,  or  by  forcible  instrumental  dilatation  with. 
Priestley's  or  Ellis's  dilator  or  some  modification  of 
these. 

Endo-metritis  has  recently  been  the  subject  of  con- 
siderable investigation.  Scanzoni,  Routh,  and  others^ 
have    written   much  upon  it;    Dr.  Hall  Davis  has  ex- 


398  UTEIUNB    SURGERT. 

hibited,  at  tlie  Pathological  Society,  tlie  uterus  oP  a 
woman  wlio  died  of  this  affection ;  and  Dr.  Oldham 
has  shown  me  a  number  of  valuable  specimens  in  the 
extensive  Museum  of  Guy's  Hospital  illustrative  of  the 
varieties  of  this  disease,  which  may  exist  in  various 
degrees  of  intensity,  from  a  merely  congested  and 
eroded  state  of  the  uterine  mucous  membrane  to  the 
extent  of  great  disorganization. 

General  constitutional  remedies  are,  of  course,  in- 
dicated, but  are  here  never  of  any  great  value  without 
local  treatment.  Nothing  in  uterine  disease  is  more 
difficult  to  remedy  than  endo-metritis.  The  first  great 
principle  to  guide  us  is  that  of  insuring  a  very  free 
exit  from  the  cavity  of  the  uterus  for  the  secretions 
therein  generated.  The  second  is  that  of  appropriate 
local  applications  to  this  cavity  for  the  purpose  of 
modifying  or  healing,  as  it  were,  its  diseased  surface. 
Where  the  canal  of  the  cervix  is  contracted,  I  have 
freely  divided  it,  as  in  cases  of  dysmenorrhoea  depen- 
dent upon  mechanical  obstruction  ;  and  this  with  great 
relief.  Indeed,  while  menstruation  continues,  it  is 
almost  impossible  to  treat  successfully  a  case  of  endo- 
metritis, without  adopting  this  principle  of  practice  in 
some  form.  The  uterine  secretions  must  not  remain 
pent  up  in  its  cavity.  With  a  patulous  cervix,  we  may 
use  medicated  injections,  or  apply  nitrate  of  silver  in 
ointment,  as  recommended  and  successfully  done  by 
Professor  Fordyce  Barker,  of  New  York.  There  is  a 
mild  form  of  endo-metritis  that  seemingly  gives  rise  to 
no  secretions  whatever,  which,  nevertheless,  is  attended 
with  great  suffering,  and  often  passes  unnoticed,  or 
rather  undetected  for  a  long  time.  Dr.  Routh  has 
particularly  noticed  this  form,  and  calls  it  fundal  endo- 
metritis.     We  can  diagnose  this  with  great  accuracy. 


ENDOMETRITIS.  399 

Place  the  patient  in  tbe  left  lateral  semi-prone  ].(osltlon  ; 
introduce  the  lever  speculum,  hook  a  tenaculum  slightly 
in  the  anterior  lip  of  the  ostincse;  draw  this  gently 
forwards,  pulling  the  os  open  so  as  to  be  able  to  look 
right  into  it;  then  pass  the  sound,  previously  warmed, 
gently  along  the  cervix,  using  no  force  whatever,  but 
almost  letting  it  go  by  its  own  gravity,  as  it  were,  to 
the  fundus.  This  is  attended  with  no  pain  whatever  till 
the  sensitive  point  be  reached,  when  it  produces  the  most 
intense  agony,  a  pain  that  does  not  cease  sometimes  for 
hours  after  the  experiment.  I  have  seen  many  cases  of 
this  sort.  And  I  now  call  to  mind  a  most  accom- 
plished lady  from  one  of  the  Southern  States  who  had 
been  married  for  six  or  seven  years  without  issue ;  and 
who,  soon  after  marriage,  passed  into  a  state  of  chi-onic 
bad  health,  and  became  a  confirmed  invalid.  For  three 
or  four  years  she  did  not  pretend  to  walk ;  and  was 
always  carried  from  the  house  to  the  carriage  whenever 
she  drove  out.  Indeed  her  time  was  spent  mostly  in 
bed  or  on  a  lounge.  Fortunately  she  was  able  to  eat, 
and  so  her  strength  and  embonpoint  were  kept  up  in 
spite  of  her  sufferings.  Her  greatest  agony  was  to  be 
found  in  a  never-ceasing  pain  in  the  left  hip  about  the 
joint.  She  had  a  granular  erosion  of  the  os  and  cervix, 
attended  with  a  leucorrhoeal  discharge,  which  were 
cured  in  the  course  of  two  months.  But  the  pain  in 
the  left  hip,  and  her  utter  inability  to  walk,  continued 
in  spite  of  all  we  did.  Thinking  that  the  diseased  con- 
dition of  the  cervix  was  the  principal  source  of  all  her 
troubles,  and  that  the  pain  in  the  hip  furnished  merely 
an  example  of  Sir  Benjamin  Brodie's  hysterical  joint, 
I  had  made  no  further  uterine  explorations,  and  was 
quite  surprised  to  find  my  patient  no  bettei*  in  any 
particular  after  the    cervical  erosion  and  its  dischaige 


400  UTERINE  SURGERY.. 

were  cured.  And  now,  for  the  first  time,  I  explored 
the  cavity  of  the  uterus.  When  the  sound  passed 
the  OS  internum  my  patient  complained  of  intense 
agony,  but  alinost  the  whole  of  it  was  referred  to  the 
left  hip. 

Dr.  Alonzo  Clark  was  called  in  consultation,  and 
ngreed  to  the  line  of  treatment  to  be  adopted,  viz., 
that  of  applying  I'emedies  to  the  uterine  cavity.  The 
canal  of  the  cei-vix  was  dihited,  and  the  disease,  with 
its  painful  symptoms,  was  perfectly  cured  in  a  few 
weeks,  simply  by  injecting  the  cavity  of  the  uterus 
with  a  few  drops  of  glycerine  two  or  three  times  a 
week.  This  was  in  1858.  In  the  course  of  a  year  after 
this,  our  patient  became  a  mother  and  has  had  other 
children  since. 

Mr.  Holmes  Coote  and  Dr.  Gi^enhalg:h  are  at  this 
moment  ctttending  a  case  of  endo-metritis  with  me, 
where  the  pain  is  almost  wholly  in  the  left  hip  and  left 
inguinal  region.  By  touching  even  the  canal  of  the 
cervix  with  the  sound  in  the  gentlest  manner  possible, 
a  most  intense  pain  slioots  at  once  to  the  left  hip  and 
groin.  Here  there  is  not  only  pain  but  tumefaction  of 
the  affected  parts,  as  we  often  see  in  some  forms  of 
hysterical  hypersesthesia. 

A  short  time  ago,  I  saw  a  patient  with  Dr.  Thierry- 
Meig,  in  Paris,  who,  besides  other  evidences  of  uterine 
trouble,  complained  greatly  of  pain  in  the  left  ovarian, 
left  mammary,  and  epigastric  regions.  Her  symptoms, 
a^  a  whole,  all  pointed  to  the  uterus  as  their  origin ; 
but  a  superficial  examination  failed  to  demonstrate  their 
relationship.  The  position  of  the  organ  was  noi-mal ; 
there  was  apparently  no  hyperti'ophy  of  the  fundus ; 
there  was  no  leucorrhoea,  and  no  engorgement  of  the 
cervix;    but   by   placing    the   patient   in    the    pio2)er 


ENDOMETRITIS.  4Q1 

position,  and  making  the  exploration  of  the  cavity  as 
above  directed,  the  gentle  passage  of  tlie  sound  along 
the  canal  of  the  cervix  was  attended  by  a  sudden  ex- 
udation of  blood  in  small  quantity,  and  a  severe  pain, 
which  became  more  severe  as  the  sound  reached  the 
fundus  uteri,  from  which  point  the  pain  radiated  to 
the  other  foci  of  sufferino:  above  indicated.  The  exuda- 
tion  of  a  small  quantity  of  blood,  by  the  j^assage  of  the 
sound  alono^  the  canal  of  the  cervix,  is  a  common  si2:n 
of  subacute  inflammation  of  the  utero-cervical  canal. 

In  this  case  a  single  sponge-tent,  followed  by  the 
injection  of  half  a  drachm  of  the  officinal  Ti".  of  Iodine, 
produced  almost  complete  relief  at  once.  A  repetition 
of  the  same,  ten  or  twelve  days  afterwards,  produced  a 
perfect  cure.  For  the  past  two  years  this  patient  had 
been  under  the  treatment  of  several  other  phj'sicians, 
without  the  least  benefit. 

I  think  it  highly  probable  that  many  unexplained 
neuralgic  pains  may  yet  be  found  out  to  be  sj'mptomatic 
of  some  slight  endo-metritic  aifection  ;  of  which  the 
case  last  mentioned  may  be  taken  as  a  type. 

It  is  very  probable  that  when  we  shall  turn  our 
attention  more  to  the  investigation  of  the  condition  of 
the  cavity  of  the  womb,  we  shall  be  able  to  detect,  to 
explain,  and  to  remedy  its  abnormal  states  with  as 
much  certainty  as  we  now  treat  many  affections  of  the 
cervix  and  its  canal. 

In  many  cases  in  which  the  spermatozoa  are  found 
to  die  quickly  in  the  canal  of  the  cervix,  the  real  source 
of  the  mischief  may  yet  be  found  to  exist  in  the  cavity 
of  the  uterus. 

26 


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